CMS/EIP Fiscal Report Statewide
Services beginning 10/01/2023 ending 12/31/2023 Date of Report:01/14/2024 Page: 1
List order: No List
Payclass Filters:TPIN
Eligibility Filter:Part C (excluding not eligible)
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
CASE-CASE-NON-TCM CASE MANAGEMENT 5 1.250000 46.5000 37.2000
TCM-T1017TL-TARGETED CASE MANAGEMENT 67 115.750000 4305.9000 37.2000
Subtotal (Total Children Is Unduplicated) 70 117.000000 4352.4000 37.2000
-----------------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
AACIS-92597-AAC INTIAL EVAL BY LICENSED SLP 1 1.000000 103.3600 103.3600
ASTE-ASTE-ASSISTIVE TECHNOLOGY EVAL 1 1.000000 48.5000 48.5000
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) 4 4.000000 35.2400 8.8100
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 4 4.000000 115.6800 28.9200
AUDE-92588-OTOACOUSTIC EMISSIONS (COMP) 4 4.000000 84.1600 21.0400
EXIT-EXIT-COS Exit 1 0.750000 37.5000 50.0000
IPDEF-IPDEF_NM-F/U PSYCH & DEV EVAL BY NON-MED PROF 1 2.000000 111.0000 55.5000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 23 43.887200 3291.5400 75.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 3 5.500000 373.5000 67.9091
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 7 13.500000 1012.5000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 6 9.072533 680.4400 75.0000
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 6 11.500000 862.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 7 15.000000 1125.0000 75.0000
IPDEF-T1024TLTSGT-F/U PHYC AND DEV EVAL BY EI PROF 4 6.000000 450.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 8 13.000000 721.5000 55.5000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 6 12.000000 666.0000 55.5000
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 314 619.853467 45858.2400 73.9824
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 177 342.000000 25612.5000 74.8904
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 136 253.000000 18670.1400 73.7950
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 100 195.380000 14653.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 96 169.099800 12468.7450 73.7360
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 66 120.500000 9037.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 272 505.000000 28066.5000 55.5772
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 198 369.000000 20559.0000 55.7154
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 104 204.468000 15260.1000 74.6332
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 97 169.500000 12712.5000 75.0000
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 10 10.000000 3040.0000 304.0000
OCTF-97168-OT RE-EVAL EST PLAN CARE 11 11.000000 565.5100 51.4100
OCTH-97165-OT EVAL LOW COMPLEXITY 19 19.000000 976.7900 51.4100
OCTH-97166-OT EVAL MODERATE COMPLEXITY 10 11.000000 514.1000 46.7364
OCTH-97166GT-OT EVAL MODERATE COMPLEXITY 2 2.000000 102.8200 51.4100
OCTH-97167-OT EVAL HIGH COMPLEXITY 7 7.000000 359.8700 51.4100
PSTF-97164-PT RE-EVAL EST PLAN CARE 1 1.000000 51.4100 51.4100
PSTH-97161-PT EVAL LOW COMPLEXITY 12 12.000000 616.9200 51.4100
PSTH-97162-PT EVAL MODERATE COMPLEXITY 5 7.000000 298.1500 42.5929
PSTH-97162GT-PT EVAL MODERATE COMPLEXITY 1 1.000000 51.4100 51.4100
PSTH-97163-PT EVAL HIGH COMPLEXITY 1 1.000000 51.4100 51.4100
PSTH-97163GT-PT EVAL HIGH COMPLEXITY 1 1.000000 51.4100 51.4100
SCREEN-T1023-SCREENING 3 3.000000 150.0000 50.0000
SPCH-92521-EVAL OF SPEECH FLUENCY 35 35.000000 1799.3500 51.4100
SPCH-92521GT-EVAL OF SPEECH FLUENCY 2 2.000000 102.8200 51.4100
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 40 41.000000 2076.5900 50.6485
SPCH-92523GT-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 3 3.000000 154.2300 51.4100
SPL-92526-TREATMENT OF SWALLOWING DYSFUNCTION 37 160.000000 7814.3200 48.8395
Subtotal (Total Children Is Unduplicated) 1137 3430.011000 231586.5150 67.5177
-----------------------------------------------------------------------------------------------------------------------
EI Services,Class #03
AACFIT-92609-AAC FITTING, ADJUST, TRAINING VISIT 2 2.000000 84.8200 42.4100
ASST-ASST-ASSISTIVE TECHNOLOGY 9 17.000000 5419.3200 318.7835
COIFF-COIFFGT-IFSP CONSULT, PROF, TELEMEDICINE 1 1.000000 50.0000 50.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 1 1.000000 50.0000 50.0000
DSTT-DSTT-DIRECT SERVICE COORDINATOR TRAVEL 3 2.750000 0.0000 0.0000
EIIF-96154-HEALTH AND BEHAVIOR INTERVENTION 14 40.000000 2000.0000 50.0000
EIIF-EIIF_NM-EI INDIVIDUAL SESSION BY NONMED PROF 3 3.000000 150.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 822 3177.750000 158669.5000 49.9314
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 118 289.000000 14437.2000 49.9557
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 1 1.000000 12.0000 12.0000
OCCT-97530-OT SESSION BY LICENSED OT 506 2340.020000 165260.9800 70.6237
OCCT-97530GT-OT SESSION BY LICENSED OT 45 98.250000 7070.0700 71.9600
OCCT-97530HM-OT SESSION BY OT ASST 72 301.674131 16925.6000 56.1056
OCCT-97530HMGT-OT SESSION BY OT ASST 3 6.500000 374.4000 57.6000
OCCT-97530TL-OT SESSION BY LICENSED OT 2 4.000000 287.8400 71.9600
PHY-97110-PT SESSION BY LICENSED PT 553 2434.928849 172198.3300 70.7201
PHY-97110GT-PT SESSION BY LICENSED PT 24 38.750000 2788.4500 71.9600
PHY-97110HM-PT SESSION BY PT ASST 49 207.397672 11880.2500 57.2825
PHY-97110HMGT-PT SESSION BY LICENSED PT ASST 6 11.000000 633.1600 57.5600
PHY-97110TL-PT SESSION BY LICENSED PT 1 1.000000 71.9600 71.9600
SENS-V5264-EARMOLD 2 3.000000 54.3900 18.1300
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 920 4720.223370 332560.0120 70.4543
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 64 203.020000 14432.8700 71.0909
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 13 71.250000 4104.0000 57.6000
CMS/EIP Fiscal Report Statewide
Services beginning 10/01/2023 ending 12/31/2023 Date of Report:01/14/2024 Page: 2
List order: No List
Payclass Filters:TPIN
Eligibility Filter:Part C (excluding not eligible)
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
SPL-92507HMGT-SPL THERAPY SESSION BY SLP ASST 4 23.250000 1339.2000 57.6000
SPL-92507TL-SPL THERAPY SESSION BY LICENSED SLP 1 2.000000 143.9200 71.9600
SPL-92507TLGT-SPL THERAPY SESSION BY LICENSED SLP 1 1.000000 71.9600 71.9600
SPL-92508HA-GROUP SPL SESSION PER CHILD 1 4.000000 55.8400 13.9600
Subtotal (Total Children Is Unduplicated) 2483 14005.76402 911126.0720 65.0537
-----------------------------------------------------------------------------------------------------------------------
Total 17552.775022 1147064.9870 65.3495
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 3402
-----------------------------------------------------------------------------------------------------------------------
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 1338 1354.750000 74250.9000 74250.9000
D 50 50.000000 2763.5200 0.0000
S 1 1.000000 71.9600 0.0000
H 308 376.500000 25310.7400 0.0000
T 904 909.000000 48357.8500 48482.2700
117 138.500000 8806.6300 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 2718 2829.750000 159561.6000 122733.1700
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 472 324.750000 23782.0300 23724.7700
46 28.000000 2014.8800 0.0000
Other 1 0.750000 53.9700 53.9700
---------------------------------------------------------
Total 519 353.500000 25850.8800 23778.7400
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 16 16.500000 975.3400 975.3400
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 3 3.000000 150.0000 150.0000
T 0 0.000000 0.0000 0.0000
209 257.500000 16460.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 228 277.000000 17585.3400 1125.3400
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 36 74.500000 4858.5600 4432.6700
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
79 110.000000 10431.8600 0.0000
Other 136 292.000000 20521.0700 555.1300
---------------------------------------------------------
Total 251 476.500000 35811.4900 4987.8000
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 64 61.000000 3763.4600 3763.4600
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
7 7.000000 503.7200 503.7200
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 71 68.000000 4267.1800 4267.1800
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 281 233.250000 14904.3600 14904.3600
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
545 651.750000 42916.3700 0.0000
Other 24 14.750000 548.7000 0.0000
---------------------------------------------------------
Total 850 899.750000 58369.4300 14904.3600
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 763 763.197800 53583.1350 53583.1300
D 3 6.000000 450.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 10 20.000000 1500.0000 0.0000
T 0 0.000000 0.0000 0.0000
90 164.250000 12006.9000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 866 953.447800 67540.0350 53583.1300
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 608 1987.500000 138133.9400 138121.9800
D 7 22.000000 1511.1600 0.0000
S 0 0.000000 0.0000 0.0000
H 95 154.000000 10400.9300 10400.9300
T 0 0.000000 0.0000 0.0000
168 459.250000 32451.2100 0.0000
Other 6 11.000000 649.5000 0.0000
---------------------------------------------------------
Total 884 2633.750000 183146.7400 148522.9100
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 1265 2206.750000 149925.9600 149925.9600
D 2 2.500000 179.9000 0.0000
S 6 5.500000 128.9400 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
1236 1944.500000 134169.7400 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 2509 4159.250000 284404.5400 149925.9600
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 11 30.000000 1977.2000 1977.2000
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
4 13.000000 335.4600 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 15 43.000000 2312.6600 1977.2000
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 77 83.500000 5537.1400 4425.4000
D 76 74.750000 5450.4500 0.0000
S 0 0.000000 0.0000 0.0000
H 89 110.250000 7993.7000 0.0000
T 1082 1136.750000 63904.0200 56881.0100
461 494.250000 29968.9500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 1785 1899.500000 112854.2600 61306.4100
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 11 6.680000 650.0800 485.6800
D 118 120.940000 7905.8700 0.0000
S 0 0.000000 0.0000 0.0000
H 89 90.500000 6468.9700 0.0000
T 54 55.500000 4726.2100 4726.2100
353 370.500000 25366.1200 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 625 644.120000 45117.2500 5211.8900
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 11 8.080000 753.8800 610.1400
D 60 62.300000 4148.3800 0.0000
S 0 0.000000 0.0000 0.0000
H 117 124.500000 8546.5000 0.0000
T 338 347.140000 18607.0500 18607.0500
440 451.860000 29583.6700 0.0000
Other 4 4.000000 287.8400 0.0000
---------------------------------------------------------
Total 970 997.880000 61927.3200 19217.1900
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 235 239.750000 16258.8400 16258.8400
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 26 47.500000 3551.8600 0.0000
T 0 0.000000 0.0000 0.0000
428 415.327222 28029.3920 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 689 702.577222 47840.0920 16258.8400
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 12 9.604924 681.7400 125.0000
D 14 14.540857 960.2000 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 48 58.000000 3859.7400 3859.7400
398 532.604219 34974.4900 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 472 614.750000 40476.1700 3984.7400