CMS/EIP Fiscal Report Statewide
Services beginning 07/01/2022 ending 06/30/2023 Date of Report:07/25/2023 Page: 1
List order: No List
Payclass Filters:MED
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 1 1.000000 37.2000 37.2000
TCM-T1017TL-TARGETED CASE MANAGEMENT 29912 183126.6183 6799640.9100 37.1308
Subtotal (Total Children Is Unduplicated) 29912 183127.6183 6799678.1100 37.1308
-----------------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
AUDE-92550-TYMPANOMETRY & REFLEX THRESH 1 1.000000 15.8400 15.8400
AUDE-92552-PURE TONE AUDIOMETRY -AIR ONLY 4 4.000000 78.0400 19.5100
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 4 4.000000 58.7200 14.6800
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 3 3.000000 21.6000 7.2000
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 4 4.000000 115.6800 28.9200
AUDE-92588-OTOACOUSTIC EMISSIONS (COMP) 4 4.000000 84.1600 21.0400
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 142 270.166667 20223.5000 74.8556
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 167 301.500000 22536.0000 74.7463
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 29 51.500000 3862.5000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 111 193.000000 14445.7500 74.8484
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 56 104.500000 7837.5000 75.0000
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 69 126.000000 9450.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 60 118.000000 8840.2500 74.9174
IPDEF-T1024TLTSGT-F/U PHYC AND DEV EVAL BY EI PROF 59 111.500000 8362.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 158 288.000000 15956.2500 55.4036
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 312 569.500000 31579.5000 55.4513
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 2402 4374.990534 327981.0400 74.9673
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 3465 6186.666666 463430.0000 74.9079
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 695 1205.000000 90337.5000 74.9689
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 1928 3348.500000 251053.5000 74.9749
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 853 1595.500000 119625.0000 74.9765
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 1258 2219.000000 166395.7500 74.9868
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 3284 5889.500000 326784.0000 55.4859
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 5405 9509.000000 527621.7000 55.4866
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 1370 2339.500000 175225.0000 74.8985
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 1370 2541.500000 190612.5000 75.0000
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 22 22.000000 1649.6800 74.9855
MED-99205-OUTPATIENT VISIT, NEW, 60 MINS 1 2.000000 284.4600 142.2300
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 1 1.000000 31.1700 31.1700
OCTF-97168-OT RE-EVAL EST PLAN CARE 39 50.000000 2567.9800 51.3596
OCTH-97165-OT EVAL LOW COMPLEXITY 84 86.500000 4441.3850 51.3455
OCTH-97165GT-OT EVAL LOW COMPLEXITY 3 3.000000 154.2300 51.4100
OCTH-97165TL-OT EVAL LOW COMPLEXITY 11 11.000000 565.5100 51.4100
OCTH-97166-OT EVAL MODERATE COMPLEXITY 55 58.000000 2978.5400 51.3541
OCTH-97166GT-OT EVAL MODERATE COMPLEXITY 11 11.000000 564.7900 51.3445
OCTH-97166TL-OT EVAL MODERATE COMPLEXITY 5 5.000000 257.0500 51.4100
OCTH-97166TLGT-OT EVAL MODERATE COMPLEXITY 7 7.000000 359.8700 51.4100
OCTH-97167-OT EVAL HIGH COMPLEXITY 73 86.000000 4416.9400 51.3598
OCTH-97167GT-OT EVAL HIGH COMPLEXITY 3 3.000000 153.8700 51.2900
OCTH-97167TL-OT EVAL HIGH COMPLEXITY 1 1.000000 51.0500 51.0500
OCTH-97167TLGT-OT EVAL HIGH COMPLEXITY 1 2.000000 102.8200 51.4100
PSTF-97164-PT RE-EVAL EST PLAN CARE 14 18.000000 925.0200 51.3900
PSTH-97161-PT EVAL LOW COMPLEXITY 33 31.000000 1592.2700 51.3635
PSTH-97161TL-PT EVAL LOW COMPLEXITY 3 3.000000 154.2300 51.4100
PSTH-97162-PT EVAL MODERATE COMPLEXITY 8 8.000000 410.5600 51.3200
PSTH-97162GT-PT EVAL MODERATE COMPLEXITY 1 1.000000 51.0500 51.0500
PSTH-97162TL-PT EVAL MODERATE COMPLEXITY 2 2.000000 102.8200 51.4100
PSTH-97163-PT EVAL HIGH COMPLEXITY 27 32.000000 1642.9600 51.3425
PSTH-97163GT-PT EVAL HIGH COMPLEXITY 4 8.000000 410.9200 51.3650
PSTH-97163TL-PT EVAL HIGH COMPLEXITY 6 6.000000 308.4600 51.4100
PSTH-97163TLGT-PT EVAL HIGH COMPLEXITY 1 1.000000 51.4100 51.4100
SCREEN-T1023-SCREENING 130 133.000000 6650.0000 50.0000
SPCH-92521-EVAL OF SPEECH FLUENCY 142 142.750000 7326.1775 51.3217
SPCH-92521GT-EVAL OF SPEECH FLUENCY 8 7.500000 384.8550 51.3140
SPCH-92521TL-EVAL OF SPEECH FLUENCY 4 5.000000 257.0500 51.4100
SPCH-92521TLGT-EVAL OF SPEECH FLUENCY 1 1.000000 51.4100 51.4100
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 74 79.000000 4026.0500 50.9627
SPCH-92523GT-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 2 3.000000 154.2300 51.4100
SPCH-92523TL-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 31 32.000000 1644.0400 51.3763
SPCH-92523TLGT-EVAL OF SPCH SOUND PROD; EVAL LANG COM 9 11.000000 565.5100 51.4100
SPCH-92610-EVAL OF ORAL,PHARYNGEAL SWALLOWING FUNC 4 5.000000 216.6200 43.3240
SPL-92526-TREATMENT OF SWALLOWING DYSFUNCTION 3 14.000000 740.6600 52.9043
SPL-92526TL-TREATMENT OF SWALLOWING DYSFUNCTION 15 86.000000 4544.6200 52.8444
Subtotal (Total Children Is Unduplicated) 12537 42340.57387 2833324.0475 66.9175
-----------------------------------------------------------------------------------------------------------------------
EI Services,Class #03
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 1 13.000000 325.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 9372 149238.0000 7459128.7400 49.9814
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 3087 25427.25000 1270819.0000 49.9786
OCCT-97530-OT SESSION BY LICENSED OT 880 9421.692242 676497.0800 71.8021
OCCT-97530GT-OT SESSION BY LICENSED OT 132 671.380000 48103.7600 71.6491
OCCT-97530HM-OT SESSION BY OT ASST 369 4540.250000 261147.3400 57.5183
OCCT-97530HMGT-OT SESSION BY OT ASST 23 80.000000 4565.1600 57.0645
OCCT-97530TL-OT SESSION BY LICENSED OT 253 1884.000000 135254.2100 71.7910
CMS/EIP Fiscal Report Statewide
Services beginning 07/01/2022 ending 06/30/2023 Date of Report:07/25/2023 Page: 2
List order: No List
Payclass Filters:MED
Eligibility Filter:Program Patients
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
OCCT-97530TLGT-OT SESSION BY LICENSED OT 133 477.750000 34321.1700 71.8392
OCCT-97530TLGTHM-OT SESSION BY OT ASST 10 17.500000 1004.2000 57.3829
OCCT-97530TLHM-OT SESSION BY OT ASST 25 238.000000 13696.4000 57.5479
PHY-97110-PT SESSION BY LICENSED PT 720 8765.250000 629542.4300 71.8225
PHY-97110GT-PT SESSION BY LICENSED PT 66 313.500000 22457.7100 71.6354
PHY-97110HM-PT SESSION BY PT ASST 136 2132.750000 122512.3400 57.4434
PHY-97110HMGT-PT SESSION BY LICENSED PT ASST 14 53.250000 3063.0700 57.5224
PHY-97110TL-PT SESSION BY LICENSED PT 274 2603.250000 187022.1900 71.8418
PHY-97110TLGT-PT SESSION BY LICENSED PT 95 176.250000 12652.5300 71.7874
PHY-97110TLGTHM-PT SESSION BY PT ASST 2 2.000000 115.1200 57.5600
PHY-97110TLHM-PT SESSION BY PT ASST 11 146.750000 8438.9300 57.5055
SENS-V5264-EARMOLD 1 1.000000 18.1300 18.1300
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 1200 15701.45000 1127560.1600 71.8125
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 213 1102.250000 78857.4300 71.5422
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 18 79.250000 4552.2000 57.4410
SPL-92507HMGT-SPL THERAPY SESSION BY SLP ASST 2 18.750000 1080.0000 57.6000
SPL-92507TL-SPL THERAPY SESSION BY LICENSED SLP 339 2960.910000 212651.7600 71.8197
SPL-92507TLGT-SPL THERAPY SESSION BY LICENSED SLP 144 569.750000 40877.8500 71.7470
SPL-92508HA-GROUP SPL SESSION PER CHILD 1 0.500000 6.9400 13.8800
SPL-92508TLGT-SPL THERAPY SESSION BY LICENSED SLP 2 2.000000 27.9200 13.9600
Subtotal (Total Children Is Unduplicated) 12736 226637.6822 12356298.7700 54.5201
-----------------------------------------------------------------------------------------------------------------------
Total 452105.874389 21989300.9275 48.6375
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 30982
-----------------------------------------------------------------------------------------------------------------------
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 14 14.000000 551.5600 551.5600
D 494 503.250000 26333.4200 0.0000
S 18 30.500000 2024.2500 0.0000
H 30301 21370.500000 911081.5700 910894.6200
T 4 4.000000 184.0000 137.5000
333 204.250000 7654.2000 7002.9000
Other 1084 1362.750000 87747.9500 0.0000
---------------------------------------------------------
Total 32248 23489.250000 1035576.9500 918586.5800
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 0 0.000000 0.0000 0.0000
0 0.000000 0.0000 0.0000
Other 6418 4882.500000 211148.9500 0.0000
---------------------------------------------------------
Total 6418 4882.500000 211148.9500 0.0000
Center 03
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 107 145.500000 5412.6000 0.0000
U 0 0.000000 0.0000 0.0000
B 6184 4286.000000 165996.2400 0.0000
P 2910 2029.750000 80467.5500 80281.4800
D 82 83.250000 3621.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 1 2.000000 150.0000 150.0000
T 0 0.000000 0.0000 0.0000
1865 1448.750000 56702.2300 0.0000
Other 263 259.000000 9913.7000 0.0000
---------------------------------------------------------
Total 11412 8254.250000 322263.3200 80431.4800
Center 04
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 210 326.500000 12902.5500 0.0000
U 0 0.000000 0.0000 0.0000
B 5978 8978.500000 357464.0500 0.0000
P 7138 11391.000000 455718.6000 450651.3300
D 982 1409.750000 54457.0500 27.8600
S 5 6.500000 241.5000 0.0000
H 9036 33881.000000 1707708.0300 210.0000
T 1 3.000000 111.0000 0.0000
999 1186.250000 74327.3300 0.0000
Other 4 12.250000 519.7000 0.0000
---------------------------------------------------------
Total 24353 57194.750000 2663449.8100 450889.1900
Center 05
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 40 23.500000 874.2000 0.0000
U 0 0.000000 0.0000 0.0000
B 12388 7764.250000 288411.0000 236329.9100
P 0 0.000000 0.0000 0.0000
D 68 34.250000 1268.1000 83.2500
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
13 8.000000 297.6000 0.0000
Other 37 27.500000 1023.0000 0.0000
---------------------------------------------------------
Total 12546 7857.500000 291873.9000 236413.1600
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 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 0 0.000000 0.0000 0.0000
48416 43506.250000 2068978.8700 0.0000
Other 1 1.000000 37.2000 0.0000
---------------------------------------------------------
Total 48417 43507.250000 2069016.0700 0.0000
Center 07
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 90 70.750000 3083.1000 0.0000
U 0 0.000000 0.0000 0.0000
B 1989 1666.750000 75993.6000 0.0000
P 10000 8525.500000 373736.3600 373464.1200
D 163 105.500000 4057.2000 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
36 32.000000 1341.6000 0.0000
Other 144 92.000000 4024.8000 -150.0000
---------------------------------------------------------
Total 12422 10492.500000 462236.6600 373314.1200
Center 09
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 199 200.250000 7828.5400 0.0000
U 0 0.000000 0.0000 0.0000
B 8558 9225.750000 375548.3300 5517.5100
P 8609 9350.500000 376139.5600 374837.8500
D 4 6.500000 241.8000 0.0000
S 1 2.000000 102.8200 51.0500
H 0 0.000000 0.0000 0.0000
T 6 3.000000 111.6000 111.0000
8072 27190.000000 1485228.2700 0.0000
Other 628 1192.750000 82020.8500 0.0000
---------------------------------------------------------
Total 26077 47170.750000 2327221.7700 380517.4100
Center 10
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 99 80.250000 3154.2000 0.0000
U 0 0.000000 0.0000 0.0000
B 39682 34843.500000 1468527.1500 0.0000
P 222 295.750000 16375.7500 408.5000
D 496 641.000000 39532.9900 0.0000
S 23 65.000000 3827.8400 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
20581 58617.000000 3342107.1075 0.0000
Other 526 370.250000 13901.0400 0.0000
---------------------------------------------------------
Total 61629 94912.750000 4887426.0775 408.5000
Center 51
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 2 2.500000 138.7500 0.0000
U 0 0.000000 0.0000 0.0000
B 40 55.000000 3453.7500 0.0000
P 1 4.000000 200.0000 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 0 0.000000 0.0000 0.0000
1987 5985.000000 367109.2100 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 2030 6046.500000 370901.7100 0.0000
Center 52
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 13 13.000000 685.6200 0.0000
U 0 0.000000 0.0000 0.0000
B 1969 2018.750000 108979.3200 130.2000
P 7117 7553.000000 354262.8600 474129.2400
D 42 62.250000 3851.5500 287.9000
S 575 506.250000 22078.2000 1963.3000
H 13 13.000000 847.6400 0.0000
T 2 3.000000 215.8800 0.0000
2867 5414.750000 317698.6600 0.0000
Other 1 2.000000 150.0000 150.0000
---------------------------------------------------------
Total 12599 15586.000000 808769.7300 476660.6400
Center 53
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 186 188.500000 13240.8100 0.0000
U 0 0.000000 0.0000 0.0000
B 1410 1296.250000 64434.8600 0.0000
P 12392 11552.960000 573743.3500 573543.5600
D 56 64.250000 3887.1900 0.0000
S 174 180.000000 9266.0000 0.0000
H 19 21.400000 1219.0800 0.0000
T 0 0.000000 0.0000 0.0000
6038 6294.250000 330742.4700 0.0000
Other 615 513.000000 24844.1800 145.8900
---------------------------------------------------------
Total 20890 20110.610000 1021377.9400 573689.4500
Center 54
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 12 14.000000 520.8000 0.0000
U 0 0.000000 0.0000 0.0000
B 2503 2401.250000 114818.0200 0.0000
P 20940 19366.180000 891041.8500 890153.5900
D 91 97.000000 5971.6900 0.0000
S 33 31.860000 1884.2700 37.2000
H 18 18.560000 1265.7200 0.0000
T 0 0.000000 0.0000 0.0000
8202 8822.500000 468449.4700 0.0000
Other 377 338.190000 18068.5800 1633.3300
---------------------------------------------------------
Total 32176 31089.540000 1502020.4000 891824.1200
Center 55
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 3824 3868.703067 177195.0800 0.0000
P 10289 10237.706933 437675.1700 437140.5600
D 1 0.250000 9.3000 0.0000
S 10 13.413867 930.0400 37.5000
H 1 0.500000 18.6000 0.0000
T 0 0.000000 0.0000 0.0000
16176 16780.250000 1016935.0100 0.0000
Other 1 0.250000 9.3000 9.3000
---------------------------------------------------------
Total 30302 30901.073867 1632772.5000 437187.3600
Center 57
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 25 44.500000 1954.2000 0.0000
U 0 0.000000 0.0000 0.0000
B 4785 6949.750000 303470.9000 139.5000
P 9987 14794.368280 627590.6000 627065.2260
D 5 8.750000 324.3500 92.5000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 174 265.750000 13268.6500 9085.3500
7661 28172.032242 1422682.5900 1422682.4900
Other 409 375.500000 13953.8500 93.0000
---------------------------------------------------------
Total 23046 50610.650522 2383245.1400 2059158.0660