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
Agency Filter:EIP DEI DEIP
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
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Screening, Eval, and Assessment,Class #02
AACIS-92597-AAC INTIAL EVAL BY LICENSED SLP 1 1.000000 103.3600 103.3600
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 19 36.887200 2766.5400 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 4 7.500000 562.5000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 2 3.000000 225.0000 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 6 13.500000 1012.5000 75.0000
IPDEF-T1024TLTSGT-F/U PHYC AND DEV EVAL BY EI PROF 3 4.000000 300.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 7 11.000000 610.5000 55.5000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 2 4.000000 222.0000 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 267 529.853467 39299.6100 74.1707
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 173 336.500000 25200.0000 74.8886
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 98 184.000000 13596.2000 73.8924
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 92 179.880000 13491.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 90 157.099800 11617.5050 73.9498
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 60 110.000000 8250.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 234 432.000000 24015.0000 55.5903
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 155 290.500000 16202.2500 55.7737
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 101 196.468000 14660.1000 74.6183
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 89 152.000000 11400.0000 75.0000
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 10 10.000000 3040.0000 304.0000
OCTH-97166GT-OT EVAL MODERATE COMPLEXITY 2 2.000000 102.8200 51.4100
OCTH-97167-OT EVAL HIGH COMPLEXITY 1 1.000000 51.4100 51.4100
SCREEN-T1023-SCREENING 3 3.000000 150.0000 50.0000
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 3 3.000000 154.2300 51.4100
SPCH-92523GT-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 1 1.000000 51.4100 51.4100
SPL-92526-TREATMENT OF SWALLOWING DYSFUNCTION 11 35.000000 1799.3500 51.4100
Subtotal (Total Children Is Unduplicated) 877 2722.188467 190174.7850 69.8610
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EI Services,Class #03
AACFIT-92609-AAC FITTING, ADJUST, TRAINING VISIT 2 2.000000 84.8200 42.4100
ASST-ASST-ASSISTIVE TECHNOLOGY 6 14.000000 1007.4400 71.9600
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-EIIF_NM-EI INDIVIDUAL SESSION BY NONMED PROF 3 3.000000 150.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 170 620.500000 31025.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 31 87.000000 4337.2000 49.8529
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 1 1.000000 12.0000 12.0000
OCCT-97530-OT SESSION BY LICENSED OT 63 255.270000 18370.6100 71.9654
OCCT-97530GT-OT SESSION BY LICENSED OT 23 42.500000 3058.3000 71.9600
OCCT-97530HM-OT SESSION BY OT ASST 3 5.000000 288.0000 57.6000
OCCT-97530TL-OT SESSION BY LICENSED OT 2 4.000000 287.8400 71.9600
PHY-97110-PT SESSION BY LICENSED PT 83 331.500000 24190.8200 72.9738
PHY-97110GT-PT SESSION BY LICENSED PT 10 9.000000 647.6400 71.9600
PHY-97110TL-PT SESSION BY LICENSED PT 1 1.000000 71.9600 71.9600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 100 451.960000 32220.5000 71.2906
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 17 30.270000 2178.6100 71.9726
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
Subtotal (Total Children Is Unduplicated) 419 1865.750000 118246.6200 63.3775
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Total 4704.938467 312773.8050 66.4778
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Number of Children (Unduplicated) With at Least One Service 1310
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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 1 1.000000 50.0000 0.0000
S 1 1.000000 71.9600 0.0000
H 308 376.500000 25310.7400 0.0000
T 0 0.000000 0.0000 0.0000
117 138.500000 8806.6300 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 427 517.000000 34239.3300 0.0000
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 2 3.500000 262.5000 456.4800
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
78 106.500000 10180.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 80 110.000000 10442.5000 456.4800
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
288 439.000000 28700.3200 0.0000
Other 24 14.750000 548.7000 0.0000
---------------------------------------------------------
Total 312 453.750000 29249.0200 0.0000
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 3 2.447800 183.5850 183.5800
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 106 192.697800 14140.4850 183.5800
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 39 39.500000 1567.3400 1567.3400
D 0 0.000000 0.0000 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
36 61.250000 4273.5000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 170 254.750000 16241.7700 11968.2700
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 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
380 814.000000 56233.5000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 380 814.000000 56233.5000 0.0000
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 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
1 1.000000 55.5000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 1 1.000000 55.5000 0.0000
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 437 461.750000 25664.8600 18641.8500
233 257.000000 14091.1700 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 912 987.250000 58737.3200 23067.2500
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 0 0.000000 0.0000 0.0000
242 255.000000 17284.4600 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 460 473.120000 32309.3800 485.6800
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 0 0.000000 0.0000 0.0000
302 324.250000 21905.3000 0.0000
Other 4 4.000000 287.8400 0.0000
---------------------------------------------------------
Total 494 523.130000 35641.9000 610.1400
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 0 0.000000 0.0000 0.0000
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
31 42.740667 3129.4900 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 57 90.240667 6681.3500 0.0000
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 1 1.500000 112.5000 125.0000
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
176 286.500000 18689.2500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 177 288.000000 18801.7500 125.0000