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: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 8 7.250000 269.7000 37.2000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 1 0.500000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 67 183.608872 6823.6500 37.1641
Subtotal (Total Children Is Unduplicated) 72 191.358872 7093.3500 37.0683
-----------------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
ASTE-ASTE-ASSISTIVE TECHNOLOGY EVAL 2 3.000000 145.5000 48.5000
AUD-92626-EVAL OF AUD REHAB STATUS 1 1.000000 56.1000 56.1000
AUDE-92550-TYMPANOMETRY & REFLEX THRESH 11 11.000000 159.9600 14.5418
AUDE-92552-PURE TONE AUDIOMETRY -AIR ONLY 155 177.000000 3468.2700 19.5947
AUDE-92553-PURE TONE AUDIOMETRY AIR & BONE 1 1.000000 23.5000 23.5000
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 191 217.000000 3102.0800 14.2953
AUDE-92557-COMP AUDIO THRESHOLD EVAL/SPCH RECOG 1 1.000000 22.0700 22.0700
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 197 219.000000 1665.1400 7.6034
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 202 225.000000 6417.0200 28.5201
AUDE-92582-CONDITIONED PLAY AUDIOMETRY 3 3.000000 134.9200 44.9733
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 19 19.000000 262.0900 13.7942
AUDE-92588-OTOACOUSTIC EMISSIONS (COMP) 155 177.000000 3708.7100 20.9532
AUDE-V5010-ASSESSMENT FOR HEARING AID 7 8.000000 344.2800 43.0350
AUDE-V5090-DISPENSING FEE PER HEARING AID 8 13.000000 1500.6700 115.4362
EVAL-96111-DEVELOPMENTAL EVALUATION 11 17.308600 865.4300 50.0000
EVAL-96111GT-DEVELOPMENTAL EVALUATION 2 3.000000 150.0000 50.0000
EXIT-EXIT-EXIT ASSESSMENT 15 17.852600 830.1300 46.4991
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 71 138.745866 9653.9600 69.5802
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 74 137.000000 10102.5000 73.7409
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 33 62.000000 4650.0000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 47 92.500000 6787.5000 73.3784
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 25 41.579200 3118.4400 75.0000
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 27 55.000000 4086.0000 74.2909
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 36 70.500000 5287.5000 75.0000
IPDEF-T1024TLTSGT-F/U PHYC AND DEV EVAL BY EI PROF 28 48.500000 3618.0000 74.5979
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 71 129.500000 7187.2500 55.5000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 89 170.500000 9413.6100 55.2118
IPDEI-IPDEI_NM-INITIAL PSYCH & DEV EVAL BY NON-MED PR 1 1.000000 55.5000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 1340 2607.114997 189323.5750 72.6180
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 1492 2777.457100 206746.1825 74.4372
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 564 1082.311599 79699.1300 73.6379
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 892 1746.500000 130025.2100 74.4490
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 492 915.904833 68016.1125 74.2611
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 612 1191.312967 88336.2625 74.1503
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 1029 1939.143782 107072.2300 55.2162
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 2123 3893.000000 214741.7500 55.1610
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 702 1246.662300 93253.4325 74.8025
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 634 1124.079700 83800.3825 74.5502
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 97 98.000000 29336.3000 299.3500
MED-99205-OUTPATIENT VISIT, NEW, 60 MINS 6 9.000000 952.4300 105.8256
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 5 5.000000 480.4100 96.0820
OCTF-97168-OT RE-EVAL EST PLAN CARE 40 43.927636 2233.0100 50.8338
OCTF-97168GT-OT RE-EVAL EST PLAN CARE 1 1.000000 51.4100 51.4100
OCTH-97165-OT EVAL LOW COMPLEXITY 92 98.318793 4874.0100 49.5735
OCTH-97165GT-OT EVAL LOW COMPLEXITY 5 5.000000 257.0500 51.4100
OCTH-97166-OT EVAL MODERATE COMPLEXITY 96 112.141412 5350.0200 47.7078
OCTH-97166GT-OT EVAL MODERATE COMPLEXITY 23 24.000000 1191.2200 49.6342
OCTH-97167-OT EVAL HIGH COMPLEXITY 98 99.576547 5113.1100 51.3485
OCTH-97167GT-OT EVAL HIGH COMPLEXITY 5 5.000000 256.3300 51.2660
PSTF-97164-PT RE-EVAL EST PLAN CARE 39 42.890891 2092.1000 48.7773
PSTF-97164GT-PT RE-EVAL EST PLAN CARE 6 6.000000 308.4600 51.4100
PSTH-97161-PT EVAL LOW COMPLEXITY 95 99.000000 4774.9350 48.2317
PSTH-97161GT-PT EVAL LOW COMPLEXITY 1 1.000000 51.4100 51.4100
PSTH-97162-PT EVAL MODERATE COMPLEXITY 33 37.000000 1709.8100 46.2111
PSTH-97162GT-PT EVAL MODERATE COMPLEXITY 1 1.000000 51.4100 51.4100
PSTH-97163-PT EVAL HIGH COMPLEXITY 31 33.000000 1654.8400 50.1467
SCREEN-T1023-SCREENING 69 76.000000 3504.0000 46.1053
SPCH-92521-EVAL OF SPEECH FLUENCY 231 253.417090 12757.8125 50.3431
SPCH-92521GT-EVAL OF SPEECH FLUENCY 14 14.000000 719.3800 51.3843
SPCH-92521TL-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-92522GT-EVAL OF SPCH SOUND PROD 1 1.000000 51.0500 51.0500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 276 301.059149 14991.6000 49.7962
SPCH-92523GT-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 20 20.000000 1027.8400 51.3920
SPCH-92610-EVAL OF ORAL,PHARYNGEAL SWALLOWING FUNC 5 5.000000 224.3000 44.8600
SPL-92526-TREATMENT OF SWALLOWING DYSFUNCTION 54 439.383574 22060.0925 50.2069
SPL-92526TL-TREATMENT OF SWALLOWING DYSFUNCTION 1 8.000000 421.9200 52.7400
Subtotal (Total Children Is Unduplicated) 6723 22424.18864 1464429.4775 65.3058
-----------------------------------------------------------------------------------------------------------------------
EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 50 115.000000 57212.7300 497.5020
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 7 10.500000 325.0000 30.9524
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 1 2.000000 18.7500 9.3750
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:TPIN
Eligibility Filter:Program Patients
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 3 7.000000 200.0000 28.5714
CONIF-CONIFGT-CONSULT, ITDS, TELEMEDICINE 2 2.000000 100.0000 50.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 1 0.250000 12.5000 50.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 2 2.000000 100.0000 50.0000
DSTT-DSTT-DIRECT SERVICE COORDINATOR TRAVEL 9 9.000000 0.0000 0.0000
EIIF-96154-HEALTH AND BEHAVIOR INTERVENTION 134 390.750000 17272.5000 44.2035
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 1690 18799.50000 922401.2500 49.0652
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 669 3625.000000 180975.0000 49.9241
INTR-T1013-INTERPRETER 3 4.250000 212.5000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 22 42.000000 420.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 992 10803.51371 752735.6694 69.6751
OCCT-97530GT-OT SESSION BY LICENSED OT 157 688.370000 48053.6900 69.8079
OCCT-97530HM-OT SESSION BY OT ASST 219 2902.832186 161273.7600 55.5574
OCCT-97530HMGT-OT SESSION BY OT ASST 21 75.250000 4210.8600 55.9583
OCCT-97530TL-OT SESSION BY LICENSED OT 4 10.000000 719.6000 71.9600
OCCT-97530TLGT-OT SESSION BY LICENSED OT 4 11.000000 788.4400 71.6764
PHY-97110-PT SESSION BY LICENSED PT 986 12035.39372 828583.6400 68.8456
PHY-97110GT-PT SESSION BY LICENSED PT 132 500.880000 33746.4200 67.3743
PHY-97110HM-PT SESSION BY PT ASST 100 1066.892384 61009.2200 57.1840
PHY-97110HMGT-PT SESSION BY LICENSED PT ASST 24 89.500000 4810.9100 53.7532
PHY-97110TL-PT SESSION BY LICENSED PT 5 21.500000 1547.1400 71.9600
SENS-V5014-*HEARING AID REPAIR BY MANUFACTURER 1 2.000000 130.0000 65.0000
SENS-V5050-IN EAR MONAURAL HEARING AID 5 10.000000 2286.4400 228.6440
SENS-V5060-BEHIND EAR HEARING AID 2 2.000000 459.2200 229.6100
SENS-V5140-BEHIND EAR BINAURAL HEARING AID 3 3.000000 1377.6600 459.2200
SENS-V5264-EARMOLD 21 41.000000 741.5100 18.0856
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 2130 25472.16198 1768029.9800 69.4103
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 292 1667.750000 115216.4500 69.0850
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 17 82.567613 4574.9800 55.4089
SPL-92507HMGT-SPL THERAPY SESSION BY SLP ASST 7 16.952431 1019.5400 60.1412
SPL-92507TL-SPL THERAPY SESSION BY LICENSED SLP 7 30.000000 2157.7600 71.9253
SPL-92507TLGT-SPL THERAPY SESSION BY LICENSED SLP 5 26.000000 1867.3200 71.8200
SPL-92508HA-GROUP SPL SESSION PER CHILD 3 8.000000 107.3600 13.4200
TRAV-TRAVS-Travel by mile 17 654.000000 271.4900 0.4151
Subtotal (Total Children Is Unduplicated) 5352 79229.81402 4974969.2894 62.7916
-----------------------------------------------------------------------------------------------------------------------
Total 101845.361524 6446492.1169 63.2969
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 9589
-----------------------------------------------------------------------------------------------------------------------
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 14459 14989.750000 811790.0800 811477.6600
D 339 349.000000 19958.4000 0.0000
S 2 3.000000 161.0000 0.0000
H 1420 1733.000000 118152.5100 0.0000
T 2114 2230.500000 125402.1000 122201.7900
659 807.500000 53514.3500 50.0000
Other 43 71.000000 5042.2500 0.0000
---------------------------------------------------------
Total 19036 20183.750000 1134020.6900 933729.4500
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 2509 1967.000000 158376.9900 158768.8660
146 111.750000 7967.7100 0.0000
Other 1 2.000000 111.0000 0.0000
---------------------------------------------------------
Total 2659 2083.750000 166555.1600 158652.4460
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 2780 2995.500000 166230.1200 166230.1200
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 244 279.250000 14928.0800 14928.0800
T 0 0.000000 0.0000 0.0000
906 1051.500000 61180.0600 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 3930 4326.250000 242338.2600 181158.2000
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 588 1124.500000 82000.3100 61231.5300
D 3 8.000000 518.2400 107.9400
S 2 7.500000 209.4600 0.0000
H 4 7.500000 453.5400 0.0000
T 0 0.000000 0.0000 0.0000
416 471.000000 49668.8700 831.0800
Other 321 677.000000 46997.0700 1180.2800
---------------------------------------------------------
Total 1334 2295.500000 179847.4900 63350.8300
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 338 586.750000 31458.9600 31458.9600
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
6 7.000000 420.7900 402.1900
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 344 593.750000 31879.7500 31861.1500
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 2492 1819.250000 105799.2400 105799.2400
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
2922 3650.000000 244650.6200 0.0000
Other 4 5.250000 307.5000 0.0000
---------------------------------------------------------
Total 5418 5474.500000 350757.3600 105799.2400
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 3563 6885.213800 464586.7300 464587.6200
D 31 60.749300 4550.1175 143.9200
S 0 0.000000 0.0000 0.0000
H 117 234.000000 17550.0000 0.0000
T 0 0.000000 0.0000 0.0000
115 214.750000 15547.0000 0.0000
Other 2 4.000000 300.0000 0.0000
---------------------------------------------------------
Total 3828 7398.713100 502533.8475 464731.5400
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 2806 8659.250000 559094.2300 560168.9100
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 37 90.500000 6160.1300 6160.1300
424 886.000000 59696.1200 288.0000
Other 59 116.500000 8464.5000 0.0000
---------------------------------------------------------
Total 3326 9752.250000 633414.9800 566617.0400
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 7624 11449.000000 762269.1500 761570.9400
D 27 27.500000 1703.2700 0.0000
S 132 142.000000 3968.0200 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
5340 8903.500000 584212.0275 0.0000
Other 2 4.000000 251.2500 0.0000
---------------------------------------------------------
Total 13125 20526.000000 1352403.7175 761570.9400
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 613 1844.750000 122919.8100 122919.8100
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 3 14.000000 964.3600 964.3600
T 0 0.000000 0.0000 0.0000
31 87.500000 5568.7000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 647 1946.250000 129452.8700 123884.1700
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 443 636.000000 35171.7000 25325.1000
D 1016 1167.500000 63295.3800 535.3000
S 3 6.000000 450.0000 410.0000
H 430 584.500000 38775.7900 0.0000
T 3672 5329.630000 304056.9000 269224.8900
1059 1724.000000 104325.0725 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 6623 9447.630000 546074.8425 295495.2900
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 111 95.356440 10920.9900 8497.1700
D 818 856.533560 51754.6900 0.0000
S 5 5.500000 350.0000 0.0000
H 455 490.250000 35297.7500 0.0000
T 415 442.750000 30471.7000 30471.7000
1364 1475.750000 98086.5100 359.8000
Other 55 36.250000 2572.1900 0.0000
---------------------------------------------------------
Total 3223 3402.390000 229453.8300 39328.6700
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 75 64.520000 8117.6700 8054.2900
D 582 620.330000 38689.1200 0.0000
S 0 0.000000 0.0000 0.0000
H 471 533.750000 38464.9300 0.0000
T 1359 1468.480000 83137.8600 83009.1300
1641 1877.270000 122370.2500 0.0000
Other 10 9.750000 687.5500 0.0000
---------------------------------------------------------
Total 4138 4574.100000 291467.3800 91063.4200
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 1799 1898.897754 127309.1000 127309.1000
D 0 0.000000 0.0000 0.0000
S 1 0.833333 62.5000 0.0000
H 183 299.665509 21909.9900 0.0000
T 0 0.000000 0.0000 0.0000
2903 2766.464006 182393.4900 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 4886 4965.860602 331675.0800 127309.1000
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 314 386.614047 26578.0300 31914.1400
D 173 312.000000 20621.2500 0.0000
S 7 14.351585 854.8600 854.8600
H 28 28.000000 526.2500 526.2500
T 855 1830.535102 127633.4994 127633.5000
1143 2297.167088 147999.9300 52577.0800
Other 5 6.000000 403.0400 403.0400
---------------------------------------------------------
Total 2525 4874.667822 324616.8594 213908.8700