CMS/EIP Fiscal Report Statewide
Services beginning 07/01/2023 ending 09/30/2023 Date of Report:10/10/2023 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 10414 12567.75000 468182.5500 37.2527
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 777 767.250000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 8167 23799.25000 884788.4000 37.1772
Subtotal (Total Children Is Unduplicated) 14711 37134.25000 1352970.9500 36.4346
-----------------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
ASTE-ASTE-ASSISTIVE TECHNOLOGY EVAL 22 24.000000 1164.0000 48.5000
AUDE-92552-PURE TONE AUDIOMETRY -AIR ONLY 3 3.000000 58.5300 19.5100
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 6 6.000000 88.0800 14.6800
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 5 5.000000 44.0500 8.8100
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 5 5.000000 144.6000 28.9200
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 2 2.000000 27.6200 13.8100
AUDE-92588-OTOACOUSTIC EMISSIONS (COMP) 2 2.000000 42.0800 21.0400
AUDE-V5090-DISPENSING FEE PER HEARING AID 1 1.000000 115.8100 115.8100
EVAL-96111GT-DEVELOPMENTAL EVALUATION 5 10.000000 500.0000 50.0000
EXIT-EXIT-COS Exit 317 498.250000 24887.5000 49.9498
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 9 16.000000 1200.0000 75.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 16 30.500000 2287.5000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 5 9.000000 675.0000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 13 24.500000 1837.5000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 2.000000 150.0000 75.0000
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 7 13.000000 975.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 11 23.500000 1762.5000 75.0000
IPDEF-T1024TLTSGT-F/U PHYC AND DEV EVAL BY EI PROF 4 7.500000 562.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 34 48.000000 2664.0000 55.5000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 27 49.500000 2747.2500 55.5000
IPDEI-IPDEI_NM-INITIAL PSYCH & DEV EVAL BY NON-MED PR 2 4.000000 222.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 233 402.333334 30175.0000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 206 379.500000 28434.5500 74.9264
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 104 176.090400 13192.8400 74.9208
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 146 264.500000 19837.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 50 83.033300 6189.9975 74.5484
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 86 155.500000 11662.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 412 784.000000 43456.5000 55.4292
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 385 691.500000 38407.5000 55.5423
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 101 159.500000 11962.5000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 70 122.953000 9105.9050 74.0600
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 1 1.000000 76.1500 76.1500
OCTF-97168-OT RE-EVAL EST PLAN CARE 4 4.000000 205.6400 51.4100
OCTH-97165-OT EVAL LOW COMPLEXITY 21 20.750000 1066.7600 51.4101
OCTH-97166-OT EVAL MODERATE COMPLEXITY 11 11.000000 565.5100 51.4100
OCTH-97166GT-OT EVAL MODERATE COMPLEXITY 1 1.000000 51.4100 51.4100
OCTH-97167-OT EVAL HIGH COMPLEXITY 11 11.000000 565.5100 51.4100
OCTH-97167GT-OT EVAL HIGH COMPLEXITY 1 1.000000 51.4100 51.4100
PSTF-97164-PT RE-EVAL EST PLAN CARE 6 5.027426 258.4600 51.4100
PSTH-97161-PT EVAL LOW COMPLEXITY 10 10.000000 464.9800 46.4980
PSTH-97162-PT EVAL MODERATE COMPLEXITY 3 3.000000 154.2300 51.4100
PSTH-97163-PT EVAL HIGH COMPLEXITY 2 2.000000 102.8200 51.4100
SCREEN-T1023-SCREENING 1 1.000000 50.0000 50.0000
SPCH-92521-EVAL OF SPEECH FLUENCY 22 22.000000 1098.8500 49.9477
SPCH-92521GT-EVAL OF SPEECH FLUENCY 1 1.000000 51.4100 51.4100
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 21 22.000000 1110.7600 50.4891
SPCH-92523GT-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 3 7.000000 359.8700 51.4100
SPCH-92610-EVAL OF ORAL,PHARYNGEAL SWALLOWING FUNC 1 1.000000 44.8600 44.8600
SPL-92526-TREATMENT OF SWALLOWING DYSFUNCTION 8 19.000000 908.7800 47.8305
Subtotal (Total Children Is Unduplicated) 1665 4145.437460 261767.7225 63.1460
-----------------------------------------------------------------------------------------------------------------------
EI Services,Class #03
AACFIT-92609-AAC FITTING, ADJUST, TRAINING VISIT 2 2.000000 84.8200 42.4100
ASST-ASST-ASSISTIVE TECHNOLOGY 34 90.000000 15071.5400 167.4616
AUD-92630-AUD REHAB PRELING HEARING LOSS 2 5.000000 346.7500 69.3500
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 661 714.250000 35576.4100 49.8095
COIFF-COIFFGT-IFSP CONSULT, PROF, TELEMEDICINE 706 707.500000 35325.0000 49.9293
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 243 216.500000 5450.0000 25.1732
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 705 1393.250000 50171.3300 36.0103
CONIF-CONIFGT-CONSULT, ITDS, TELEMEDICINE 768 851.500000 38150.0000 44.8033
CONIP-CONIP-CONSULT, ITDS PHONE 53 49.750000 1243.7500 25.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 436 600.750000 26939.5000 44.8431
CONOF-CONOFGT-CONSULT, OT, TELEMEDICINE 690 656.250000 30712.5000 46.8000
CONOP-CONOP-CONSULT, OT, PHONE 41 72.500000 1812.5000 25.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 240 332.500000 16625.0000 50.0000
CONPF-CONPFGT-CONSULT, PT, TELEMEDICINE 497 350.000000 17487.5000 49.9643
CONPP-CONPP-CONSULT, PT, PHONE 12 6.250000 156.2500 25.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 549 711.250000 31412.5000 44.1652
CONSF-CONSFGT-CONSULT, SLP, TELEMEDICINE 617 558.750000 27975.0000 50.0671
CONSP-CONSP-CONSULT, SLP, PHONE 42 41.500000 1062.5000 25.6024
DSTT-DSTT-DIRECT SERVICE COORDINATOR TRAVEL 1146 4276.750000 75.0000 0.0175
EIGF-EIGF_NM-EI GROUP SESSION BY NONMED PROF 1 1.000000 15.0000 15.0000
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 4 5.000000 125.0000 25.0000
CMS/EIP Fiscal Report Statewide
Services beginning 07/01/2023 ending 09/30/2023 Date of Report:10/10/2023 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
EIIF-96154-HEALTH AND BEHAVIOR INTERVENTION 86 199.000000 9613.3000 48.3080
EIIF-EIIF_NM-EI INDIVIDUAL SESSION BY NONMED PROF 2 4.000000 200.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 2931 15669.50000 779849.2000 49.7686
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 587 1963.750000 98099.7000 49.9553
EPIC-99601-Early Steps Professional Development Fee 4520 23729.00000 341643.0000 14.3977
INTR-T1013-INTERPRETER 240 765.750000 38236.5200 49.9334
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 9002 50699.00000 605929.0000 11.9515
OCCT-97530-OT SESSION BY LICENSED OT 279 1135.126458 78399.9600 69.0672
OCCT-97530GT-OT SESSION BY LICENSED OT 25 43.250000 3227.4700 74.6236
OCCT-97530HM-OT SESSION BY OT ASST 64 250.916666 14495.0800 57.7685
OCCT-97530HMGT-OT SESSION BY OT ASST 1 3.000000 172.8000 57.6000
OCCT-97530TL-OT SESSION BY LICENSED OT 3 3.000000 215.8800 71.9600
PHY-97110-PT SESSION BY LICENSED PT 189 719.849497 47159.9100 65.5136
PHY-97110GT-PT SESSION BY LICENSED PT 11 13.000000 830.3000 63.8692
PHY-97110HM-PT SESSION BY PT ASST 38 139.522237 8030.9000 57.5600
PHY-97110HMGT-PT SESSION BY LICENSED PT ASST 5 15.750000 906.5700 57.5600
PHY-97110TL-PT SESSION BY LICENSED PT 2 3.000000 215.8800 71.9600
PHY-97110TLGT-PT SESSION BY LICENSED PT 1 0.500000 35.9800 71.9600
SENS-V5050-IN EAR MONAURAL HEARING AID 1 1.000000 229.6100 229.6100
SENS-V5264-EARMOLD 1 1.000000 18.1300 18.1300
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 505 2127.645358 148295.9900 69.6996
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 53 137.500000 9800.0600 71.2732
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 14 20.750000 1195.2000 57.6000
SPL-92507HMGT-SPL THERAPY SESSION BY SLP ASST 1 1.000000 57.6000 57.6000
TELEC-TELEC-TELECONFERENCE,PROVIDER TO FAMILY,PHONE 1 1.000000 37.0000 37.0000
TRAV-TRAVS-Travel by mile 3961 275503.0000 114994.4700 0.4174
Subtotal (Total Children Is Unduplicated) 14566 384792.0602 2637707.3600 6.8549
-----------------------------------------------------------------------------------------------------------------------
Total 426071.747676 4252446.0325 9.9806
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 22349
-----------------------------------------------------------------------------------------------------------------------
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 9352 41354.000000 149881.2400 149881.2400
D 204 1169.500000 3555.3400 0.0000
S 2 2.500000 112.2000 75.0000
H 0 0.000000 0.0000 0.0000
T 1377 5772.500000 20654.4000 20654.4000
357 335.000000 17353.4800 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 11292 48633.500000 191556.6600 170610.6400
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 2805 8281.250000 69809.5800 69674.8500
578 2247.000000 14658.0600 0.0000
Other 3313 10091.750000 67582.6500 0.0000
---------------------------------------------------------
Total 6696 20620.000000 152050.2900 69674.8500
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 2833 21745.000000 62292.1700 62292.1700
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 2890 21629.000000 63116.7800 63116.7800
T 0 0.000000 0.0000 0.0000
1146 1820.750000 30382.5600 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 6869 45194.750000 155791.5100 125408.9500
Center 04
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 1 1.000000 37.2000 0.0000
P 2466 9436.500000 205130.3300 205130.3300
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 5 19.000000 696.0000 105.0000
T 0 0.000000 0.0000 0.0000
2410 2872.500000 117696.2000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 4882 12329.000000 323559.7300 205235.3300
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 4883 53608.500000 165574.0000 165574.0000
D 25 13.000000 483.6000 55.8000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
3199 3333.500000 58383.0900 3606.0900
Other 1 0.750000 27.9000 0.0000
---------------------------------------------------------
Total 8108 56955.750000 224468.5900 169235.8900
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 5249 5197.750000 121471.9900 121471.9900
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 3 3.750000 139.5000 0.0000
8605 6690.000000 197380.6500 0.0000
Other 360 221.000000 8221.2000 0.0000
---------------------------------------------------------
Total 14217 12112.500000 327213.3400 121471.9900
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 8846 15191.250000 325972.7400 325972.7400
D 10 3.250000 120.9000 0.0000
S 1 0.250000 9.3000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
6246 3329.576700 120620.8525 49.0000
Other 5 2.750000 102.3000 0.0000
---------------------------------------------------------
Total 15108 18527.076700 446826.0925 326021.7400
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 16832 72633.000000 416295.7100 416295.7100
D 378 3219.000000 3791.7300 3499.2400
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 1624 11581.750000 33141.8700 33141.8700
1204 1305.750000 53065.5300 0.0000
Other 73 141.000000 9834.0000 0.0000
---------------------------------------------------------
Total 20111 88880.500000 516128.8400 452936.8200
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 7510 17709.750000 475436.3500 475458.3100
D 8 8.500000 229.9400 0.0000
S 36 48.750000 1731.5800 100.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
5209 4339.000000 174109.5000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 12763 22106.000000 651507.3700 475558.3100
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 1098 3009.000000 82242.7200 82242.6800
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
12 19.500000 572.8500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 1110 3028.500000 82815.5700 82242.6800
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 1.250000 46.5000 0.0000
P 1 0.250000 9.3000 9.3000
D 9 8.000000 581.7600 0.0000
S 37 15.000000 558.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 4869 25408.000000 69403.0700 67948.8700
2494 3044.250000 50788.2500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 7411 28476.750000 121386.8800 67958.1700
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 175 132.500000 5832.2100 0.0000
S 4 5.500000 232.0500 0.0000
H 1 1.000000 71.9600 0.0000
T 1365 9452.000000 20070.3200 20014.8200
8994 10143.000000 156348.1600 0.0000
Other 18 10.750000 399.9000 0.0000
---------------------------------------------------------
Total 10557 19744.750000 182954.6000 20014.8200
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 190 155.000000 7276.3600 0.0000
S 1 2.000000 74.4000 0.0000
H 0 0.000000 0.0000 0.0000
T 2301 13933.500000 40008.8700 39999.5700
8721 7998.000000 175882.8100 0.0000
Other 108 86.250000 3359.7000 0.0000
---------------------------------------------------------
Total 11321 22174.750000 226602.1400 39999.5700
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 2547 3960.930547 56685.9700 56685.9700
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 1 2.000000 150.0000 0.0000
T 0 0.000000 0.0000 0.0000
8280 9216.490569 224373.5700 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 10828 13179.421116 281209.5400 56685.9700
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 4.000000 261.0000 0.0000
S 19 19.000000 849.0000 849.0000
H 3 3.000000 363.5500 363.5500
T 9246 10174.249860 216121.8000 216494.8000
3236 3757.000000 146571.9000 680.0000
Other 158 151.250000 4207.6300 4198.3300
---------------------------------------------------------
Total 12664 14108.499860 368374.8800 222585.6800