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:TPIN
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 4 4.000000 148.8000 37.2000
TCM-T1017TL-TARGETED CASE MANAGEMENT 20 27.750000 1032.3000 37.2000
Subtotal (Total Children Is Unduplicated) 23 31.750000 1181.1000 37.2000
-----------------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
ASTE-ASTE-ASSISTIVE TECHNOLOGY EVAL 2 3.000000 145.5000 48.5000
AUDE-92550-TYMPANOMETRY & REFLEX THRESH 3 3.000000 47.5200 15.8400
AUDE-92552-PURE TONE AUDIOMETRY -AIR ONLY 5 5.000000 97.5500 19.5100
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 10 10.000000 146.8000 14.6800
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 6 6.000000 43.2000 7.2000
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 12 12.000000 347.0400 28.9200
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 3 3.000000 41.4300 13.8100
AUDE-92588-OTOACOUSTIC EMISSIONS (COMP) 6 7.000000 126.2400 18.0343
EVAL-96111-DEVELOPMENTAL EVALUATION 1 1.000000 50.0000 50.0000
EVAL-96111GT-DEVELOPMENTAL EVALUATION 1 2.000000 100.0000 50.0000
EXIT-EXIT-EXIT ASSESSMENT 4 3.000000 137.5000 45.8333
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 19 37.000000 2737.5000 73.9865
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 18 34.500000 2558.2500 74.1522
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 12 21.500000 1612.5000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 9 16.000000 1200.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 8 15.000000 1125.0000 75.0000
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 5 12.000000 900.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 13 20.500000 1537.5000 75.0000
IPDEF-T1024TLTSGT-F/U PHYC AND DEV EVAL BY EI PROF 5 9.000000 675.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 15 27.000000 1498.5000 55.5000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 21 42.500000 2358.7500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 407 799.528834 57830.6325 72.3309
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 331 618.464300 46378.3125 74.9895
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 135 258.854932 18986.8400 73.3493
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 213 391.500000 29312.5000 74.8723
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 135 257.258299 19122.6225 74.3324
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 119 213.000000 15975.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 298 565.000000 31329.7500 55.4509
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 509 939.000000 51952.8000 55.3278
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 179 302.665900 22624.9425 74.7522
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 70 134.500000 10087.5000 75.0000
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 26 26.000000 7904.0000 304.0000
MED-99205-OUTPATIENT VISIT, NEW, 60 MINS 1 1.000000 142.2300 142.2300
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 1 1.000000 31.4700 31.4700
OCTF-97168-OT RE-EVAL EST PLAN CARE 7 6.227777 305.9100 49.1203
OCTH-97165-OT EVAL LOW COMPLEXITY 24 24.000000 1157.2800 48.2200
OCTH-97165GT-OT EVAL LOW COMPLEXITY 1 1.000000 51.4100 51.4100
OCTH-97166-OT EVAL MODERATE COMPLEXITY 21 24.000000 1131.4500 47.1438
OCTH-97166GT-OT EVAL MODERATE COMPLEXITY 8 9.000000 420.0700 46.6744
OCTH-97167-OT EVAL HIGH COMPLEXITY 15 17.000001 873.9700 51.4100
OCTH-97167GT-OT EVAL HIGH COMPLEXITY 1 1.000000 51.4100 51.4100
PSTF-97164-PT RE-EVAL EST PLAN CARE 8 8.000000 382.8400 47.8550
PSTH-97161-PT EVAL LOW COMPLEXITY 27 27.000000 1361.7700 50.4359
PSTH-97162-PT EVAL MODERATE COMPLEXITY 2 2.000000 102.8200 51.4100
PSTH-97163-PT EVAL HIGH COMPLEXITY 8 8.000000 410.9200 51.3650
SCREEN-T1023-SCREENING 17 17.000000 850.0000 50.0000
SPCH-92521-EVAL OF SPEECH FLUENCY 37 37.000000 1902.1700 51.4100
SPCH-92521GT-EVAL OF SPEECH FLUENCY 1 1.000000 51.4100 51.4100
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 58 61.000000 2972.9700 48.7372
SPCH-92523GT-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 4 4.000000 205.6400 51.4100
SPL-92526-TREATMENT OF SWALLOWING DYSFUNCTION 33 146.750000 7531.5425 51.3223
SPL-92526TL-TREATMENT OF SWALLOWING DYSFUNCTION 1 7.000000 368.9900 52.7129
Subtotal (Total Children Is Unduplicated) 1747 5198.750043 349296.9525 67.1886
-----------------------------------------------------------------------------------------------------------------------
EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 14 27.000000 16407.2500 607.6759
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 2 2.000000 100.0000 50.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 1 1.000000 50.0000 50.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 1 0.250000 12.5000 50.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 1 1.000000 50.0000 50.0000
DSTT-DSTT-DIRECT SERVICE COORDINATOR TRAVEL 5 4.750000 0.0000 0.0000
EIIF-96154-HEALTH AND BEHAVIOR INTERVENTION 55 146.000000 6597.5000 45.1884
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 885 4759.750000 228345.0000 47.9742
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 350 1124.750000 56237.5000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 4 4.000000 40.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 481 2450.228779 171335.8600 69.9265
OCCT-97530GT-OT SESSION BY LICENSED OT 61 208.120000 14814.0000 71.1801
OCCT-97530HM-OT SESSION BY OT ASST 102 685.500003 38516.0700 56.1868
OCCT-97530HMGT-OT SESSION BY OT ASST 7 25.500000 1468.6600 57.5945
OCCT-97530TL-OT SESSION BY LICENSED OT 3 5.000000 359.8000 71.9600
OCCT-97530TLGT-OT SESSION BY LICENSED OT 1 1.000000 71.9600 71.9600
PHY-97110-PT SESSION BY LICENSED PT 554 2999.853386 206558.5400 68.8562
PHY-97110GT-PT SESSION BY LICENSED PT 43 113.000000 8003.3100 70.8258
PHY-97110HM-PT SESSION BY PT ASST 61 279.250000 16102.4700 57.6633
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:TPIN
Eligibility Filter:Program Patients
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
PHY-97110HMGT-PT SESSION BY LICENSED PT ASST 12 28.250000 1444.5500 51.1345
PHY-97110TL-PT SESSION BY LICENSED PT 2 3.500000 251.8600 71.9600
SENS-V5264-EARMOLD 3 3.000000 54.3900 18.1300
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 1018 5849.193578 406733.0100 69.5366
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 120 351.250000 24477.6500 69.6873
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 7 26.928647 1378.2900 51.1830
SPL-92507HMGT-SPL THERAPY SESSION BY SLP ASST 4 9.000000 561.4800 62.3867
SPL-92507TL-SPL THERAPY SESSION BY LICENSED SLP 1 3.000000 215.8800 71.9600
SPL-92507TLGT-SPL THERAPY SESSION BY LICENSED SLP 2 3.000000 215.8800 71.9600
SPL-92508HA-GROUP SPL SESSION PER CHILD 2 7.000000 97.7200 13.9600
TRAV-TRAVS-Travel by mile 1 36.000000 16.0200 0.4450
Subtotal (Total Children Is Unduplicated) 2869 19158.07439 1200517.1500 62.6638
-----------------------------------------------------------------------------------------------------------------------
Total 24388.574436 1550995.2025 63.5952
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 4211
-----------------------------------------------------------------------------------------------------------------------
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 2169 2346.000000 118936.4800 118672.0600
D 58 61.000000 3532.9800 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 2007 2113.500000 117808.2000 114652.8900
2 2.000000 60.0000 50.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 4236 4522.500000 240337.6600 233374.9500
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 3 3.000000 99.4600 -116.4200
H 0 0.000000 0.0000 0.0000
T 582 416.250000 33110.2900 33788.6760
139 107.750000 6938.7900 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 724 527.000000 40148.5400 33672.2560
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 217 275.750000 13239.3200 13239.3200
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 174 186.500000 9815.6000 9815.6000
T 0 0.000000 0.0000 0.0000
753 843.500000 46750.6400 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 1144 1305.750000 69805.5600 23054.9200
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 35 77.000000 4703.6700 3084.5700
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
142 170.500000 18409.3000 831.0800
Other 122 241.500000 16655.2200 604.4400
---------------------------------------------------------
Total 299 489.000000 39768.1900 4520.0900
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 68 121.750000 6989.1200 6989.1200
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
4 6.500000 402.1900 402.1900
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 72 128.250000 7391.3100 7391.3100
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 254 202.250000 12058.8200 12058.8200
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
872 959.750000 62153.0000 0.0000
Other 4 5.250000 307.5000 0.0000
---------------------------------------------------------
Total 1130 1167.250000 74519.3200 12058.8200
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 536 1122.832800 76755.1700 76755.1600
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 42 84.000000 6300.0000 0.0000
T 0 0.000000 0.0000 0.0000
50 97.750000 7227.9000 0.0000
Other 2 4.000000 300.0000 0.0000
---------------------------------------------------------
Total 630 1308.582800 90583.0700 76755.1600
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 557 1866.500000 132445.3900 132445.3900
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 23 64.000000 4474.8800 4474.8800
194 380.000000 25365.9600 0.0000
Other 22 43.500000 3145.5000 0.0000
---------------------------------------------------------
Total 796 2354.000000 165431.7300 136920.2700
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 1648 2851.250000 192866.7900 192866.7900
D 9 10.000000 719.6000 0.0000
S 3 4.500000 323.8200 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
1289 2324.500000 157814.9800 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 2949 5190.250000 351725.1900 192866.7900
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 61 217.750000 14798.0200 14798.0200
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
11 36.000000 2266.6800 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 72 253.750000 17064.7000 14798.0200
Center 52
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 82 123.000000 6281.1100 4322.7900
D 188 209.000000 11153.4600 172.8000
S 1 2.000000 150.0000 130.0000
H 274 356.750000 23708.9700 0.0000
T 977 1417.250000 76829.0300 69478.8300
344 501.250000 31754.4925 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 1866 2609.250000 149877.0625 74104.4200
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 4 4.000000 640.0000 448.0000
D 54 57.500000 3028.2600 0.0000
S 4 4.000000 200.0000 0.0000
H 43 43.500000 3136.3400 0.0000
T 118 122.000000 14604.8000 14604.8000
723 772.000000 50679.4100 0.0000
Other 1 1.000000 71.9600 0.0000
---------------------------------------------------------
Total 947 1004.000000 72360.7700 15052.8000
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 9 6.310000 721.9200 641.9200
D 51 56.000000 3769.2800 0.0000
S 0 0.000000 0.0000 0.0000
H 81 82.750000 5936.0200 0.0000
T 251 275.750000 15514.6600 15385.9300
775 877.500000 56643.4900 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 1167 1298.310000 82585.3700 16027.8500
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 321 339.500000 22652.3600 22652.3600
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 82 149.000000 11047.2000 0.0000
T 0 0.000000 0.0000 0.0000
730 736.690301 48424.2800 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 1133 1225.190301 82123.8400 22652.3600
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 26 33.526139 2211.4300 3632.4300
D 21 36.500000 2406.0000 0.0000
S 1 0.851585 61.2800 61.2800
H 0 0.000000 0.0000 0.0000
T 89 194.613611 13522.5600 13522.5600
350 737.000000 48884.4600 20388.2700
Other 4 3.000000 187.1600 187.1600
---------------------------------------------------------
Total 491 1005.491335 67272.8900 37791.7000