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: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 2 0.750000 27.9000 37.2000
TCM-T1017TL-TARGETED CASE MANAGEMENT 68 127.500000 4743.0000 37.2000
Subtotal (Total Children Is Unduplicated) 68 128.250000 4770.9000 37.2000
-----------------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
AUDE-92552-PURE TONE AUDIOMETRY -AIR ONLY 24 25.000000 487.7500 19.5100
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 30 31.000000 455.0800 14.6800
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 29 30.000000 264.3000 8.8100
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 28 29.000000 838.6800 28.9200
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 3 3.000000 41.4300 13.8100
AUDE-92588-OTOACOUSTIC EMISSIONS (COMP) 25 26.000000 547.0400 21.0400
AUDE-V5010-ASSESSMENT FOR HEARING AID 1 1.000000 45.3200 45.3200
AUDE-V5090-DISPENSING FEE PER HEARING AID 1 1.000000 115.8100 115.8100
EVAL-96111GT-DEVELOPMENTAL EVALUATION 2 4.000000 200.0000 50.0000
EXIT-EXIT-COS Exit 1 0.500000 25.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 11 24.500000 1672.7000 68.2735
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 20 40.000000 3000.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 7 13.500000 1012.5000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 13 24.000000 1800.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 3 6.000000 450.0000 75.0000
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 7 13.500000 1012.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 7 7.500000 562.5000 75.0000
IPDEF-T1024TLTSGT-F/U PHYC AND DEV EVAL BY EI PROF 9 17.500000 1262.5000 72.1429
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 7 12.500000 693.7500 55.5000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 29 53.500000 2969.2500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 349 709.666666 51335.3500 72.3373
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 316 572.000000 42735.2000 74.7119
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 161 314.409600 23391.7200 74.3989
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 183 330.500000 24787.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 126 249.466700 18350.4025 73.5585
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 80 144.000000 10761.0000 74.7292
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 262 493.000000 27361.5000 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 382 696.000000 38628.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 140 236.500000 17687.5000 74.7886
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 85 156.047000 11653.5250 74.6796
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 17 17.000000 5168.0000 304.0000
OCTF-97168-OT RE-EVAL EST PLAN CARE 7 8.000000 411.2800 51.4100
OCTF-97168GT-OT RE-EVAL EST PLAN CARE 1 1.000000 51.4100 51.4100
OCTH-97165-OT EVAL LOW COMPLEXITY 13 13.000000 668.3300 51.4100
OCTH-97166-OT EVAL MODERATE COMPLEXITY 17 19.000000 873.9700 45.9984
OCTH-97167-OT EVAL HIGH COMPLEXITY 12 12.000000 616.9200 51.4100
PSTF-97164-PT RE-EVAL EST PLAN CARE 3 2.972573 152.8200 51.4100
PSTH-97161-PT EVAL LOW COMPLEXITY 8 8.000000 364.0500 45.5063
PSTH-97162-PT EVAL MODERATE COMPLEXITY 3 3.000000 154.2300 51.4100
PSTH-97163-PT EVAL HIGH COMPLEXITY 7 7.000000 359.8700 51.4100
SCREEN-T1023-SCREENING 9 9.000000 450.0000 50.0000
SPCH-92521-EVAL OF SPEECH FLUENCY 51 52.000000 2673.3200 51.4100
SPCH-92521GT-EVAL OF SPEECH FLUENCY 1 1.000000 51.4100 51.4100
SPCH-92522-EVAL OF SPCH SOUND PROD 1 1.000000 51.4100 51.4100
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 31 31.000000 1593.7100 51.4100
SPCH-92523GT-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 7 7.000000 359.8700 51.4100
SPCH-92610-EVAL OF ORAL,PHARYNGEAL SWALLOWING FUNC 1 1.000000 51.4100 51.4100
SPL-92526-TREATMENT OF SWALLOWING DYSFUNCTION 38 189.500000 9653.9200 50.9442
Subtotal (Total Children Is Unduplicated) 1515 4647.062539 307853.7375 66.2470
-----------------------------------------------------------------------------------------------------------------------
EI Services,Class #03
AACFIT-92609-AAC FITTING, ADJUST, TRAINING VISIT 2 2.000000 84.8200 42.4100
ASST-ASST-ASSISTIVE TECHNOLOGY 11 23.000000 10131.5900 440.5039
COIFF-COIFFGT-IFSP CONSULT, PROF, TELEMEDICINE 1 0.750000 37.5000 50.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 1 1.000000 50.0000 50.0000
DSTT-DSTT-DIRECT SERVICE COORDINATOR TRAVEL 6 7.000000 0.0000 0.0000
EIIF-96154-HEALTH AND BEHAVIOR INTERVENTION 35 91.750000 3987.5000 43.4605
EIIF-EIIF_NM-EI INDIVIDUAL SESSION BY NONMED PROF 3 3.000000 150.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 752 2962.250000 141726.5000 47.8442
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 167 336.750000 16737.5000 49.7030
EPIC-99601-Early Steps Professional Development Fee 7 12.000000 180.0000 15.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 1 1.000000 12.0000 12.0000
OCCT-97530-OT SESSION BY LICENSED OT 472 1967.349222 138331.5400 70.3137
OCCT-97530GT-OT SESSION BY LICENSED OT 60 137.250000 9828.1600 71.6077
OCCT-97530HM-OT SESSION BY OT ASST 80 415.583334 23807.6000 57.2872
OCCT-97530HMGT-OT SESSION BY OT ASST 6 28.500000 1641.6000 57.6000
OCCT-97530TL-OT SESSION BY LICENSED OT 3 4.000000 287.8400 71.9600
OCCT-97530TLGT-OT SESSION BY LICENSED OT 1 1.000000 71.9600 71.9600
PHY-97110-PT SESSION BY LICENSED PT 525 2275.683573 159675.6100 70.1660
PHY-97110GT-PT SESSION BY LICENSED PT 33 61.500000 4397.6100 71.5059
PHY-97110HM-PT SESSION BY PT ASST 63 255.477763 14743.7000 57.7103
PHY-97110HMGT-PT SESSION BY LICENSED PT ASST 10 28.750000 1558.8500 54.2209
PHY-97110TL-PT SESSION BY LICENSED PT 1 2.000000 143.9200 71.9600
SENS-V5050-IN EAR MONAURAL HEARING AID 1 1.000000 229.6100 229.6100
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:TPIN
Eligibility Filter:Program Patients
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
SENS-V5264-EARMOLD 3 3.000000 54.3900 18.1300
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 915 4175.104642 291767.9300 69.8828
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 80 225.000000 19288.6100 85.7272
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 15 46.000000 2501.9500 54.3902
SPL-92507HMGT-SPL THERAPY SESSION BY SLP ASST 2 11.750000 676.8000 57.6000
SPL-92507TL-SPL THERAPY SESSION BY LICENSED SLP 8 18.000000 1295.2800 71.9600
SPL-92507TLGT-SPL THERAPY SESSION BY LICENSED SLP 1 0.500000 35.9800 71.9600
TRAV-TRAVS-Travel by mile 1 5.000000 2.2300 0.4460
Subtotal (Total Children Is Unduplicated) 2478 13102.94853 843438.5800 64.3701
-----------------------------------------------------------------------------------------------------------------------
Total 17878.261073 1156063.2175 64.6631
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 3755
-----------------------------------------------------------------------------------------------------------------------
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 1808 1999.750000 98761.4300 98761.4300
D 43 48.500000 2535.2300 0.0000
S 0 0.000000 0.0000 0.0000
H 324 368.750000 23324.4600 0.0000
T 100 100.000000 5510.7200 5510.7200
152 166.000000 10684.8500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 2427 2683.000000 140816.6900 104272.1500
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 422 323.750000 26006.9400 26006.9400
62 50.500000 3490.9300 0.0000
Other 1 1.000000 225.4300 0.0000
---------------------------------------------------------
Total 485 375.250000 29723.3000 26006.9400
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 145 186.750000 11423.4300 11423.4300
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 141 159.000000 9097.5200 9097.5200
T 0 0.000000 0.0000 0.0000
5 4.750000 293.7800 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 291 350.500000 20814.7300 20520.9500
Center 04
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 0 0.000000 0.0000 0.0000
P 76 142.500000 9757.1700 6457.2500
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
129 160.500000 15662.7000 0.0000
Other 59 117.000000 8096.8000 215.8800
---------------------------------------------------------
Total 264 420.000000 33516.6700 6673.1300
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 54 65.000000 3799.1800 3799.1800
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
2 3.000000 215.8800 215.8800
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 56 68.000000 4015.0600 4015.0600
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 117 94.500000 4887.4700 4887.4700
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
864 976.000000 66674.5400 0.0000
Other 2 2.000000 130.5000 0.0000
---------------------------------------------------------
Total 983 1072.500000 71692.5100 4887.4700
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 678 810.423300 56237.6575 56237.6500
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 4 8.000000 600.0000 0.0000
T 0 0.000000 0.0000 0.0000
77 147.000000 10741.8000 0.0000
Other 7 14.000000 1050.0000 0.0000
---------------------------------------------------------
Total 766 979.423300 68629.4575 56237.6500
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 1733 1763.250000 121513.9700 121580.6100
D 16 14.000000 966.3400 822.4200
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 312 310.000000 20779.1500 20779.1500
290 385.500000 25628.9100 0.0000
Other 1 2.000000 150.0000 0.0000
---------------------------------------------------------
Total 2352 2474.750000 169038.3700 143182.1800
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 1583 2062.000000 138768.7300 138753.3200
D 9 11.500000 481.7000 0.0000
S 38 37.500000 1204.0900 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
1318 2095.750000 141854.3000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 2948 4206.750000 282308.8200 138753.3200
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 18 62.500000 4458.2000 4458.2000
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 33.750000 2360.0400 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 30 96.250000 6818.2400 4458.2000
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 74 89.750000 5789.0600 4699.5500
D 68 79.750000 5850.6100 0.0000
S 1 0.750000 27.9000 0.0000
H 90 123.250000 9043.8100 48.0000
T 914 986.500000 55617.4600 50333.3900
481 537.250000 32754.1000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 1628 1817.250000 109082.9400 55080.9400
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 1 1.000000 71.9600 71.9600
D 87 108.750000 6579.4800 0.0000
S 1 2.000000 150.0000 0.0000
H 134 137.000000 9852.6000 0.0000
T 127 130.000000 6169.3900 6058.3900
369 396.750000 25891.2900 0.0000
Other 2 2.000000 143.9200 0.0000
---------------------------------------------------------
Total 721 777.500000 48858.6400 6130.3500
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 7 7.000000 1360.0000 731.1000
D 89 89.000000 5811.2400 0.0000
S 2 2.000000 143.9200 0.0000
H 121 123.500000 8643.3000 0.0000
T 248 267.440000 16042.6000 16042.6000
400 454.310000 30272.2600 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 867 943.250000 62273.3200 16773.7000
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 117 116.500000 7629.9900 7629.9900
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 60 117.000000 8665.8800 0.0000
T 0 0.000000 0.0000 0.0000
746 782.587633 52726.2800 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 923 1016.087633 69022.1500 7629.9900
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 3 2.437605 175.4100 175.4100
D 2 4.000000 261.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 52 43.500000 2916.7400 2923.9200
394 545.812535 35955.2500 8885.0900
Other 2 2.000000 143.9200 143.9200
---------------------------------------------------------
Total 453 597.750140 39452.3200 12128.3400