CMS/EIP Fiscal Report Statewide
Services beginning 04/01/2023 ending 06/30/2023 Date of Report:07/25/2023 Page: 1
List order: No List
Payclass Filters:GR
Eligibility Filter:Program Patients
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
CASE-CASE-NON-TCM CASE MANAGEMENT 11784 15681.00000 582804.2000 37.1663
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 804 785.000000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 8703 26320.33410 978651.3785 37.1823
Subtotal (Total Children Is Unduplicated) 16148 42786.33410 1561455.5785 36.4943
-----------------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
ASTE-ASTE-ASSISTIVE TECHNOLOGY EVAL 41 43.000000 2085.5000 48.5000
AUDE-92550-TYMPANOMETRY & REFLEX THRESH 1 1.000000 15.8400 15.8400
AUDE-92552-PURE TONE AUDIOMETRY -AIR ONLY 1 1.000000 19.5100 19.5100
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 14 14.000000 205.5200 14.6800
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 13 13.000000 93.6000 7.2000
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 10 10.000000 289.2000 28.9200
AUDE-92582-CONDITIONED PLAY AUDIOMETRY 3 3.000000 135.2400 45.0800
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 3 3.000000 41.4300 13.8100
AUDE-92588-OTOACOUSTIC EMISSIONS (COMP) 2 2.000000 42.0800 21.0400
BEHV-BEHV-BEHAVIORAL ASSESSMENT 1 2.000000 250.0000 125.0000
EVAL-96111-DEVELOPMENTAL EVALUATION 27 61.000000 3050.0000 50.0000
EVAL-96111GT-DEVELOPMENTAL EVALUATION 17 26.500000 1325.0000 50.0000
EXIT-EXIT-EXIT ASSESSMENT 356 553.000000 27346.2500 49.4507
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 24 39.500000 2962.5000 75.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 15 28.500000 2137.5000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 4 7.500000 562.5000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 8 16.000000 1200.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 6 9.500000 712.5000 75.0000
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 10 18.000000 1350.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 5 8.500000 637.5000 75.0000
IPDEF-T1024TLTSGT-F/U PHYC AND DEV EVAL BY EI PROF 2 4.000000 300.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 56 79.000000 4384.5000 55.5000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 22 41.000000 2275.5000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 289 496.387065 35606.0300 71.7304
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 240 430.035700 32050.6375 74.5302
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 67 119.645066 8800.4000 73.5542
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 169 314.500000 23587.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 67 114.742000 8605.6500 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 142 247.500000 18562.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 467 844.500000 46786.5000 55.4014
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 405 757.500000 42030.2500 55.4855
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 164 230.834100 17312.5575 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 55 102.000000 7592.9000 74.4402
NUTR-97802-NUTRITIONAL EVAL, INITIAL 4 11.000000 550.0000 50.0000
NUTR-97803-NUTRITIONAL EVAL, FOLLOW-UP 17 55.000000 2750.0000 50.0000
OCTF-97168-OT RE-EVAL EST PLAN CARE 4 3.772223 193.9300 51.4100
OCTH-97165-OT EVAL LOW COMPLEXITY 19 19.000000 927.3600 48.8084
OCTH-97166-OT EVAL MODERATE COMPLEXITY 10 10.000000 514.1000 51.4100
OCTH-97166GT-OT EVAL MODERATE COMPLEXITY 6 6.000000 308.4600 51.4100
OCTH-97167-OT EVAL HIGH COMPLEXITY 14 14.000000 694.8200 49.6300
PSTF-97164-PT RE-EVAL EST PLAN CARE 3 3.000000 154.2300 51.4100
PSTH-97161-PT EVAL LOW COMPLEXITY 12 12.000000 616.9200 51.4100
PSTH-97162-PT EVAL MODERATE COMPLEXITY 5 5.000000 257.0500 51.4100
PSTH-97163-PT EVAL HIGH COMPLEXITY 6 6.000000 308.4600 51.4100
PSTH-97163GT-PT EVAL HIGH COMPLEXITY 1 1.000000 51.4100 51.4100
SCREEN-T1023-SCREENING 4 4.000000 200.0000 50.0000
SPCH-92521-EVAL OF SPEECH FLUENCY 43 47.000000 2229.9200 47.4451
SPCH-92521GT-EVAL OF SPEECH FLUENCY 3 3.000000 154.2300 51.4100
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 17 17.000000 827.6500 48.6853
SPCH-92523GT-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 3 3.000000 154.2300 51.4100
SPCH-92610-EVAL OF ORAL,PHARYNGEAL SWALLOWING FUNC 1 1.000000 44.8600 44.8600
SPL-92526-TREATMENT OF SWALLOWING DYSFUNCTION 8 28.000000 1290.3800 46.0850
Subtotal (Total Children Is Unduplicated) 1988 4890.416154 304584.6050 62.2819
-----------------------------------------------------------------------------------------------------------------------
EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 28 48.000000 18701.9200 389.6233
AUD-92630-AUD REHAB PRELING HEARING LOSS 1 3.000000 208.0500 69.3500
AUDE-V5160-DISPENSING FEE BINAURAL 1 1.000000 231.6200 231.6200
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 824 903.500000 44800.9300 49.5860
COIFF-COIFFGT-IFSP CONSULT, PROF, TELEMEDICINE 938 953.000000 47550.0000 49.8951
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 325 318.250000 7843.7500 24.6465
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 853 1513.000000 66106.2500 43.6922
CONIF-CONIFGT-CONSULT, ITDS, TELEMEDICINE 866 977.250000 47362.5000 48.4651
CONIP-CONIP-CONSULT, ITDS PHONE 81 87.000000 1918.7500 22.0546
CONOF-CONOF-CONSULT, OT, FACE TO FACE 459 608.000000 29887.5000 49.1571
CONOF-CONOFGT-CONSULT, OT, TELEMEDICINE 796 785.500000 38675.0000 49.2362
CONOP-CONOP-CONSULT, OT, PHONE 25 50.000000 1210.0000 24.2000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 280 433.000000 20593.7500 47.5606
CONPF-CONPFGT-CONSULT, PT, TELEMEDICINE 563 474.250000 23675.0000 49.9209
CONPP-CONPP-CONSULT, PT, PHONE 15 14.500000 237.5000 16.3793
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 680 978.250000 45262.5000 46.2688
CONSF-CONSFGT-CONSULT, SLP, TELEMEDICINE 784 757.250000 37550.0000 49.5873
CONSP-CONSP-CONSULT, SLP, PHONE 51 51.500000 1227.5000 23.8350
CMS/EIP Fiscal Report Statewide
Services beginning 04/01/2023 ending 06/30/2023 Date of Report:07/25/2023 Page: 2
List order: No List
Payclass Filters:GR
Eligibility Filter:Program Patients
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
DSTT-DSTT-DIRECT SERVICE COORDINATOR TRAVEL 1188 3180.749700 0.0000 0.0000
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 6 14.000000 350.0000 25.0000
EIIF-96154-HEALTH AND BEHAVIOR INTERVENTION 217 662.250000 32912.5000 49.6980
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 3025 19601.25000 978523.5200 49.9215
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 663 2767.000000 138050.0000 49.8916
INTR-T1013-INTERPRETER 319 1100.250000 54467.7500 49.5049
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 13226 105003.0000 1044613.0000 9.9484
OCCT-97530-OT SESSION BY LICENSED OT 297 1376.449694 95262.1600 69.2086
OCCT-97530GT-OT SESSION BY LICENSED OT 23 71.750000 5105.6900 71.1594
OCCT-97530HM-OT SESSION BY OT ASST 80 412.999999 23418.1900 56.7026
OCCT-97530HMGT-OT SESSION BY OT ASST 3 12.250000 705.5800 57.5984
OCCT-97530TL-OT SESSION BY LICENSED OT 4 4.500000 323.8200 71.9600
OCCT-97530TLGT-OT SESSION BY LICENSED OT 3 2.500000 179.9000 71.9600
PHY-97110-PT SESSION BY LICENSED PT 235 1090.146605 75935.7500 69.6565
PHY-97110GT-PT SESSION BY LICENSED PT 21 33.500000 1988.8800 59.3696
PHY-97110HM-PT SESSION BY PT ASST 22 143.000000 8230.9500 57.5591
PHY-97110HMGT-PT SESSION BY LICENSED PT ASST 4 8.500000 441.2600 51.9129
PHY-97110TL-PT SESSION BY LICENSED PT 2 3.000000 215.8800 71.9600
SENS-V5140-BEHIND EAR BINAURAL HEARING AID 1 1.000000 459.2200 459.2200
SENS-V5264-EARMOLD 3 7.000000 126.9100 18.1300
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 579 3161.056417 219785.6300 69.5292
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 83 296.250000 20511.8400 69.2383
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 4 12.000000 691.2000 57.6000
SPL-92507TL-SPL THERAPY SESSION BY LICENSED SLP 5 8.000000 575.6800 71.9600
SPL-92507TLGT-SPL THERAPY SESSION BY LICENSED SLP 3 4.000000 287.8400 71.9600
TELEC-TELEC-TELECONFERENCE,PROVIDER TO FAMILY,PHONE 82 105.000000 3885.0000 37.0000
TRAV-TRAVS-Travel by mile 4770 427195.0000 171056.7800 0.4004
Subtotal (Total Children Is Unduplicated) 15721 575232.6524 3311147.4500 5.7562
-----------------------------------------------------------------------------------------------------------------------
Total 622909.402669 5177187.6335 8.3113
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 23919
-----------------------------------------------------------------------------------------------------------------------
Center 01
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 0 0.000000 0.0000 0.0000
P 11592 52639.250000 155662.4700 155462.4700
D 202 808.750000 2947.1500 1.7800
S 1 1.000000 10.0000 10.0000
H 0 0.000000 0.0000 0.0000
T 11981 69414.750000 168483.1100 168372.2400
131 66.000000 1347.4400 117.7800
Other 1 0.250000 9.3000 0.0000
---------------------------------------------------------
Total 23908 122930.000000 328459.4700 323964.2700
Center 02
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 0 0.000000 0.0000 0.0000
P 0 0.000000 0.0000 0.0000
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 3174 13120.500000 72853.2300 72864.4110
1006 3037.500000 21501.4300 0.0000
Other 3058 10370.750000 58377.7200 0.0000
---------------------------------------------------------
Total 7238 26528.750000 152732.3800 72864.4110
Center 03
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 0 0.000000 0.0000 0.0000
P 1409 12759.250000 28051.3300 28051.3300
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 740 5489.500000 13059.1700 13059.1700
T 0 0.000000 0.0000 0.0000
7693 44923.000000 168639.6600 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 9842 63171.750000 209750.1600 41110.5000
Center 04
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 0 0.000000 0.0000 0.0000
P 3414 13112.750000 234392.9800 234396.7800
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 6 19.000000 620.2400 230.0000
T 0 0.000000 0.0000 0.0000
2914 3382.000000 135871.7500 0.0000
Other 1 1.000000 71.9600 71.9600
---------------------------------------------------------
Total 6335 16514.750000 370956.9300 234698.7400
Center 05
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 0 0.000000 0.0000 0.0000
P 5438 56375.750000 177267.2900 177267.2900
D 16 12.250000 455.7000 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
3814 6374.500000 76725.0000 14405.7000
Other 1 0.250000 9.3000 0.0000
---------------------------------------------------------
Total 9269 62762.750000 254457.2900 191672.9900
Center 06
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 0 0.000000 0.0000 0.0000
P 9044 8942.500000 190335.4600 190335.4600
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 2 4.000000 261.0000 0.0000
7585 5770.000000 168675.7800 0.0000
Other 318 187.250000 6965.7000 0.0000
---------------------------------------------------------
Total 16949 14903.750000 366237.9400 190335.4600
Center 07
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 0 0.000000 0.0000 0.0000
P 6417 17837.750000 340740.1900 340577.1900
D 7 9.000000 431.6000 20.0000
S 1 0.250000 9.3000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
7130 3803.667200 139650.4835 147.5000
Other 1 2.000000 74.4000 0.0000
---------------------------------------------------------
Total 13556 21652.667200 480905.9735 340744.6900
Center 09
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 0 0.000000 0.0000 0.0000
P 11399 100245.000000 497403.3300 497403.3300
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 3445 7578.250000 140777.1400 140777.1400
76 80.000000 3217.9600 0.0000
Other 33 64.000000 4775.0000 0.0000
---------------------------------------------------------
Total 14953 107967.250000 646173.4300 638180.4700
Center 10
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 0 0.000000 0.0000 0.0000
P 7606 24404.750000 596582.6300 596582.6300
D 7 7.500000 298.9400 0.0000
S 24 49.500000 982.9600 60.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
5690 4957.250000 197165.2500 20.0000
Other 6 7.000000 292.4000 125.0000
---------------------------------------------------------
Total 13333 29426.000000 795322.1800 596787.6300
Center 51
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 0 0.000000 0.0000 0.0000
P 1806 5533.500000 149023.4300 149023.4300
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
1 6.000000 300.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 1807 5539.500000 149323.4300 149023.4300
Center 52
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 1 2.000000 111.0000 0.0000
P 0 0.000000 0.0000 0.0000
D 6 8.750000 424.3000 0.0000
S 3 4.250000 270.3000 0.0000
H 0 0.000000 0.0000 0.0000
T 3908 39168.250000 82631.1700 80045.2900
2422 1482.500000 48131.3500 20.0000
Other 2 2.000000 74.4000 0.0000
---------------------------------------------------------
Total 6342 40667.750000 131642.5200 80065.2900
Center 53
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 0 0.000000 0.0000 0.0000
P 0 0.000000 0.0000 0.0000
D 270 178.250000 7564.0200 0.0000
S 8 7.000000 40.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 1496 10682.750000 18396.7500 18396.7500
11377 15848.250000 180734.8200 0.0000
Other 24 19.000000 706.8000 0.0000
---------------------------------------------------------
Total 13175 26735.250000 207442.3900 18396.7500
Center 54
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 0 0.000000 0.0000 0.0000
P 0 0.000000 0.0000 0.0000
D 270 207.000000 8971.8400 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 2755 20611.750000 40571.2500 40000.2600
12660 27287.250000 229935.8600 0.0000
Other 80 52.750000 1962.3000 0.0000
---------------------------------------------------------
Total 15765 48158.750000 281441.2500 40000.2600
Center 55
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 0 0.000000 0.0000 0.0000
P 5480 8028.509330 118104.9600 118071.3600
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
7278 7434.300347 202621.5700 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 12758 15462.809677 320726.5300 118071.3600
Center 57
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 0 0.000000 0.0000 0.0000
P 0 0.000000 0.0000 0.0000
D 2 2.500000 93.0000 0.0000
S 12 25.000000 331.4100 331.4100
H 3 4.000000 727.1000 727.1000
T 4442 16574.175792 329126.1200 325976.1400
3701 3849.250000 150724.3500 0.0000
Other 12 32.750000 613.7800 585.8800
---------------------------------------------------------
Total 8172 20487.675792 481615.7600 327620.5300