CMS/EIP Fiscal Report Statewide
Services beginning 10/01/2022 ending 12/31/2022 Date of Report:01/23/2023 Page: 1
List order: No List
Payclass Filters:MED
Eligibility Filter:Part C (excluding not eligible)
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 12337 35689.25000 1326722.0000 37.1743
Subtotal (Total Children Is Unduplicated) 12337 35689.25000 1326722.0000 37.1743
-----------------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
AUDE-92552-PURE TONE AUDIOMETRY -AIR ONLY 1 1.000000 19.5100 19.5100
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 1 1.000000 14.6800 14.6800
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 1 1.000000 7.2000 7.2000
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 1 1.000000 28.9200 28.9200
AUDE-92588-OTOACOUSTIC EMISSIONS (COMP) 1 1.000000 21.0400 21.0400
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 18 34.500000 2587.5000 75.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 28 53.500000 3973.5000 74.2710
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 2 4.000000 300.0000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 27 46.500000 3458.2500 74.3710
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 7 13.500000 1012.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 7 12.000000 900.0000 75.0000
IPDEF-T1024TLTSGT-F/U PHYC AND DEV EVAL BY EI PROF 8 15.500000 1162.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 22 41.500000 2303.2500 55.5000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 53 94.500000 5142.0000 54.4127
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 315 592.500000 44437.5000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 606 1084.000000 81270.7500 74.9730
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 114 209.000000 15675.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 362 609.000000 45636.0000 74.9360
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 123 236.000000 17700.0000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 218 408.500000 30637.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 395 746.500000 41430.7500 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 989 1733.000000 96181.5000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 224 416.500000 31237.5000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 226 392.000000 29400.0000 75.0000
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 14 14.000000 1066.1000 76.1500
OCTF-97168-OT RE-EVAL EST PLAN CARE 14 15.000000 771.1500 51.4100
OCTH-97165-OT EVAL LOW COMPLEXITY 14 14.000000 719.7400 51.4100
OCTH-97165GT-OT EVAL LOW COMPLEXITY 2 2.000000 102.8200 51.4100
OCTH-97165TL-OT EVAL LOW COMPLEXITY 2 2.000000 102.8200 51.4100
OCTH-97166-OT EVAL MODERATE COMPLEXITY 11 11.000000 565.5100 51.4100
OCTH-97166GT-OT EVAL MODERATE COMPLEXITY 2 2.000000 102.8200 51.4100
OCTH-97166TLGT-OT EVAL MODERATE COMPLEXITY 1 1.000000 51.4100 51.4100
OCTH-97167-OT EVAL HIGH COMPLEXITY 17 17.000000 873.9700 51.4100
OCTH-97167GT-OT EVAL HIGH COMPLEXITY 1 1.000000 51.4100 51.4100
OCTH-97167TLGT-OT EVAL HIGH COMPLEXITY 1 2.000000 102.8200 51.4100
PSTF-97164-PT RE-EVAL EST PLAN CARE 2 2.000000 102.8200 51.4100
PSTH-97161-PT EVAL LOW COMPLEXITY 6 6.000000 308.4600 51.4100
PSTH-97162-PT EVAL MODERATE COMPLEXITY 1 1.000000 51.4100 51.4100
PSTH-97162TL-PT EVAL MODERATE COMPLEXITY 1 1.000000 51.4100 51.4100
PSTH-97163-PT EVAL HIGH COMPLEXITY 3 3.000000 154.2300 51.4100
PSTH-97163GT-PT EVAL HIGH COMPLEXITY 1 1.000000 51.4100 51.4100
SCREEN-T1023-SCREENING 29 29.000000 1450.0000 50.0000
SPCH-92521-EVAL OF SPEECH FLUENCY 23 23.500000 1206.6950 51.3487
SPCH-92522TL-EVAL OF SPCH SOUND PROD 2 2.000000 102.8200 51.4100
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 18 18.000000 925.3800 51.4100
SPCH-92523TL-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 8 8.000000 411.2800 51.4100
SPCH-92523TLGT-EVAL OF SPCH SOUND PROD; EVAL LANG COM 1 1.000000 51.4100 51.4100
SPCH-92610-EVAL OF ORAL,PHARYNGEAL SWALLOWING FUNC 2 2.000000 89.7200 44.8600
SPL-92526TL-TREATMENT OF SWALLOWING DYSFUNCTION 5 14.000000 741.0200 52.9300
Subtotal (Total Children Is Unduplicated) 2119 6955.000000 465870.9850 66.9836
-----------------------------------------------------------------------------------------------------------------------
EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 4414 28334.25000 1416282.5000 49.9848
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 1155 4964.250000 248212.5000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 454 1971.035159 141708.8300 71.8956
OCCT-97530GT-OT SESSION BY LICENSED OT 41 93.000000 6656.3000 71.5731
OCCT-97530HM-OT SESSION BY OT ASST 157 829.250000 47764.2600 57.5993
OCCT-97530HMGT-OT SESSION BY OT ASST 5 10.500000 590.3800 56.2267
OCCT-97530TL-OT SESSION BY LICENSED OT 101 377.750000 27182.8900 71.9600
OCCT-97530TLGT-OT SESSION BY LICENSED OT 38 81.000000 5828.7600 71.9600
OCCT-97530TLGTHM-OT SESSION BY OT ASST 1 0.500000 28.8000 57.6000
OCCT-97530TLHM-OT SESSION BY OT ASST 12 82.000000 4723.2000 57.6000
PHY-97110-PT SESSION BY LICENSED PT 387 1679.000000 120511.4300 71.7757
PHY-97110GT-PT SESSION BY LICENSED PT 14 54.500000 3921.8200 71.9600
PHY-97110HM-PT SESSION BY PT ASST 73 431.000000 24802.2100 57.5457
PHY-97110HMGT-PT SESSION BY LICENSED PT ASST 6 12.000000 690.7200 57.5600
PHY-97110TL-PT SESSION BY LICENSED PT 132 498.250000 35854.0700 71.9600
PHY-97110TLGT-PT SESSION BY LICENSED PT 21 26.500000 1906.9400 71.9600
PHY-97110TLGTHM-PT SESSION BY PT ASST 1 1.000000 57.5600 57.5600
PHY-97110TLHM-PT SESSION BY PT ASST 6 35.000000 2014.6000 57.5600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 585 3320.250000 238901.4300 71.9528
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 68 220.500000 15831.2000 71.7968
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 6 33.500000 1929.6000 57.6000
SPL-92507TL-SPL THERAPY SESSION BY LICENSED SLP 150 668.500000 48042.7800 71.8665
CMS/EIP Fiscal Report Statewide
Services beginning 10/01/2022 ending 12/31/2022 Date of Report:01/23/2023 Page: 2
List order: No List
Payclass Filters:MED
Eligibility Filter:Part C (excluding not eligible)
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
SPL-92507TLGT-SPL THERAPY SESSION BY LICENSED SLP 46 110.750000 7969.5700 71.9600
SPL-92508TLGT-SPL THERAPY SESSION BY LICENSED SLP 2 2.000000 27.9200 13.9600
Subtotal (Total Children Is Unduplicated) 6423 43836.28516 2401440.2700 54.7820
-----------------------------------------------------------------------------------------------------------------------
Total 86480.535159 4194033.2550 48.4968
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 13838
-----------------------------------------------------------------------------------------------------------------------
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 0 0.000000 0.0000 0.0000
D 59 60.000000 3100.7500 0.0000
S 3398 2262.750000 96931.7200 0.0000
H 0 0.000000 0.0000 0.0000
T 2 2.000000 1.0400 1.0400
0 0.000000 0.0000 0.0000
Other 108 153.000000 10342.6500 0.0000
---------------------------------------------------------
Total 3567 2477.750000 110376.1600 1.0400
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 1056 824.500000 36432.7000 0.0000
---------------------------------------------------------
Total 1056 824.500000 36432.7000 0.0000
Center 03
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 46 27.500000 1023.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 2064 1444.250000 55638.8500 0.0000
P 39 45.750000 2056.7500 2056.7500
D 3 4.250000 214.8000 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
9 10.000000 536.0000 0.0000
Other 132 137.750000 5362.7000 0.0000
---------------------------------------------------------
Total 2294 1671.500000 64982.1000 2206.7500
Center 04
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 82 112.000000 4373.1000 0.0000
U 0 0.000000 0.0000 0.0000
B 1656 2451.250000 98190.0000 0.0000
P 842 1370.500000 54831.3000 50562.4000
D 54 69.500000 2805.0000 0.0000
S 1 0.750000 27.9000 0.0000
H 1557 5761.500000 290462.7400 100.0000
T 0 0.000000 0.0000 0.0000
462 572.500000 27089.7000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 4654 10338.000000 477779.7400 50662.4000
Center 05
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 6 3.000000 111.6000 0.0000
U 0 0.000000 0.0000 0.0000
B 2733 1628.750000 60549.6000 28183.9800
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
2 0.750000 27.9000 0.0000
Other 35 24.250000 901.0000 0.0000
---------------------------------------------------------
Total 2776 1656.750000 61590.1000 28183.9800
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
10470 9181.250000 432315.6100 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 10470 9181.250000 432315.6100 0.0000
Center 07
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 15 12.250000 455.7000 0.0000
U 0 0.000000 0.0000 0.0000
B 980 769.250000 33310.3000 0.0000
P 1514 1307.250000 58554.4500 65807.7500
D 0 0.000000 0.0000 0.0000
S 13 13.250000 492.9000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
24 16.750000 774.3000 0.0000
Other 133 70.250000 2613.2500 0.0000
---------------------------------------------------------
Total 2679 2189.000000 96200.9000 65807.7500
Center 09
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 7 4.000000 148.8000 0.0000
U 0 0.000000 0.0000 0.0000
B 1726 1924.750000 77599.4700 5074.7600
P 2023 2175.250000 87384.4700 87278.9300
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 6 3.000000 111.6000 111.0000
1921 6378.250000 349895.1200 0.0000
Other 126 239.000000 16476.4500 0.0000
---------------------------------------------------------
Total 5809 10724.250000 531615.9100 92464.6900
Center 10
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 49 42.250000 1796.1000 0.0000
U 0 0.000000 0.0000 0.0000
B 8174 7033.750000 297691.8000 0.0000
P 4 13.250000 935.5200 137.5000
D 107 133.500000 7940.6600 0.0000
S 383 241.500000 9490.4200 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
3795 10868.000000 622291.9650 0.0000
Other 625 584.750000 24648.3000 0.0000
---------------------------------------------------------
Total 13137 18917.000000 964794.7650 137.5000
Center 51
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 9 13.000000 887.2500 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
377 1129.000000 69509.8600 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 386 1142.000000 70397.1100 0.0000
Center 52
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 35 36.750000 2493.7200 0.0000
U 0 0.000000 0.0000 0.0000
B 1028 1012.250000 48531.2900 27.9000
P 782 791.000000 37394.7000 158259.0800
D 0 0.000000 0.0000 0.0000
S 96 73.500000 2771.6000 0.0000
H 0 0.000000 0.0000 0.0000
T 1 2.000000 143.9200 0.0000
640 1051.000000 62245.5600 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 2582 2966.500000 153580.7900 158286.9800
Center 53
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 42 41.000000 2608.1800 0.0000
U 0 0.000000 0.0000 0.0000
B 772 724.750000 38428.6200 18.6000
P 1732 1571.250000 78346.1500 78318.0800
D 94 82.750000 4030.5100 0.0000
S 28 29.500000 1757.1800 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
1184 1183.000000 60239.5400 0.0000
Other 121 94.000000 3798.9400 0.0000
---------------------------------------------------------
Total 3973 3726.250000 189209.1200 78336.6800
Center 54
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 32 34.000000 2210.2200 0.0000
U 0 0.000000 0.0000 0.0000
B 1054 963.250000 45400.8100 9.3000
P 3722 3188.250000 147506.3300 147297.4200
D 60 58.750000 3326.4800 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
1678 1760.750000 92014.3100 0.0000
Other 111 85.500000 3806.5100 1147.2000
---------------------------------------------------------
Total 6657 6090.500000 294264.6600 148453.9200
Center 55
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 1904 1560.750000 66717.5100 0.0000
P 835 755.250000 30443.9500 30443.8000
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
3170 3217.500000 191076.7900 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 5909 5533.500000 288238.2500 30443.8000
Center 57
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 134 177.000000 6584.4000 0.0000
U 0 0.000000 0.0000 0.0000
B 1781 2491.750000 105369.9500 0.0000
P 818 1243.250000 55285.3400 55276.3460
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 81 121.250000 4510.5000 4486.3000
1284 4723.535159 239903.8000 239476.0000
Other 259 285.000000 10601.3500 0.0000
---------------------------------------------------------
Total 4357 9041.785159 422255.3400 299238.6460