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:GR
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 9563 10604.75000 394431.4000 37.1938
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 654 594.250000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 8000 22532.50000 837959.8500 37.1889
Subtotal (Total Children Is Unduplicated) 13910 33731.50000 1232391.2500 36.5353
-----------------------------------------------------------------------------------------------------------------------
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 18 19.000000 921.5000 48.5000
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 8.8100 8.8100
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 2 2.000000 57.8400 28.9200
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 1 1.000000 13.8100 13.8100
EXIT-EXIT-COS Exit 175 257.500000 12875.0000 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 28 49.512800 3713.4600 75.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 11 17.500000 1312.5000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 4 7.000000 525.0000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 7 13.500000 1012.5000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 3 4.927467 369.5600 75.0000
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 7 14.000000 1050.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 32 43.500000 3262.5000 75.0000
IPDEF-T1024TLTSGT-F/U PHYC AND DEV EVAL BY EI PROF 5 9.500000 712.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 65 86.500000 4800.7500 55.5000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 22 39.000000 2164.5000 55.5000
IPDEI-IPDEI_NM-INITIAL PSYCH & DEV EVAL BY NON-MED PR 3 6.000000 333.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 258 457.386799 34204.0100 74.7814
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 190 329.836800 24708.5100 74.9113
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 79 143.927467 10794.5600 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 170 306.620000 22996.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 93 152.900200 11467.5150 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 62 112.500000 8437.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 384 711.500000 39543.7500 55.5780
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 375 679.500000 37790.2500 55.6148
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 116 181.032000 13652.4000 75.4143
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 95 169.500000 12712.5000 75.0000
NUTR-97802-NUTRITIONAL EVAL, INITIAL 2 2.000000 100.0000 50.0000
NUTR-97803-NUTRITIONAL EVAL, FOLLOW-UP 10 38.000000 1900.0000 50.0000
OCTF-97168-OT RE-EVAL EST PLAN CARE 7 7.000000 310.8700 44.4100
OCTH-97165-OT EVAL LOW COMPLEXITY 11 11.000000 565.5100 51.4100
OCTH-97166-OT EVAL MODERATE COMPLEXITY 5 5.000000 257.0500 51.4100
OCTH-97166GT-OT EVAL MODERATE COMPLEXITY 2 2.000000 102.8200 51.4100
OCTH-97167-OT EVAL HIGH COMPLEXITY 12 12.000000 616.9200 51.4100
OCTH-97167GT-OT EVAL HIGH COMPLEXITY 1 1.000000 51.4100 51.4100
PSTF-97164-PT RE-EVAL EST PLAN CARE 4 4.000000 205.6400 51.4100
PSTH-97161-PT EVAL LOW COMPLEXITY 8 8.000000 411.2800 51.4100
PSTH-97161GT-PT EVAL LOW COMPLEXITY 1 1.000000 51.4100 51.4100
PSTH-97162-PT EVAL MODERATE COMPLEXITY 4 4.000000 205.6400 51.4100
PSTH-97162GT-PT EVAL MODERATE COMPLEXITY 1 1.000000 51.4100 51.4100
PSTH-97163-PT EVAL HIGH COMPLEXITY 10 10.000000 514.1000 51.4100
SCREEN-T1023-SCREENING 1 1.000000 50.0000 50.0000
SPCH-92521-EVAL OF SPEECH FLUENCY 25 37.000000 1891.7900 51.1295
SPCH-92521GT-EVAL OF SPEECH FLUENCY 1 1.000000 51.4100 51.4100
SPCH-92522-EVAL OF SPCH SOUND PROD 2 2.000000 102.8200 51.4100
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 28 29.000000 1490.8900 51.4100
SPCH-92523GT-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 5 5.000000 257.0500 51.4100
SPCH-92610-EVAL OF ORAL,PHARYNGEAL SWALLOWING FUNC 1 1.000000 51.4100 51.4100
SPL-92526-TREATMENT OF SWALLOWING DYSFUNCTION 18 65.000000 3131.1700 48.1718
Subtotal (Total Children Is Unduplicated) 1600 4068.143533 262059.8750 64.4176
-----------------------------------------------------------------------------------------------------------------------
EI Services,Class #03
AACFIT-92609-AAC FITTING, ADJUST, TRAINING VISIT 4 4.000000 169.6400 42.4100
ASST-ASST-ASSISTIVE TECHNOLOGY 27 41.000000 5079.8600 123.8990
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 681 760.500000 37662.5000 49.5233
COIFF-COIFFGT-IFSP CONSULT, PROF, TELEMEDICINE 729 743.000000 37112.5000 49.9495
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 246 233.750000 5893.7500 25.2139
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 733 1105.000000 53550.0000 48.4615
CONIF-CONIFGT-CONSULT, ITDS, TELEMEDICINE 799 948.500000 44875.0000 47.3115
CONIP-CONIP-CONSULT, ITDS PHONE 34 37.250000 931.2500 25.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 543 633.000000 31562.5000 49.8618
CONOF-CONOFGT-CONSULT, OT, TELEMEDICINE 542 481.750000 23962.5000 49.7405
CONOP-CONOP-CONSULT, OT, PHONE 45 69.000000 1725.0000 25.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 267 345.750000 17287.5000 50.0000
CONPF-CONPFGT-CONSULT, PT, TELEMEDICINE 423 308.500000 15425.0000 50.0000
CONPP-CONPP-CONSULT, PT, PHONE 19 14.000000 350.0000 25.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 689 818.750000 40912.5000 49.9695
CONSF-CONSFGT-CONSULT, SLP, TELEMEDICINE 638 601.750000 30087.5000 50.0000
CONSP-CONSP-CONSULT, SLP, PHONE 37 40.750000 1068.7500 26.2270
DSTT-DSTT-DIRECT SERVICE COORDINATOR TRAVEL 1093 4143.750000 229.0000 0.0553
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:GR
Eligibility Filter:Program Patients
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 3 6.000000 150.0000 25.0000
EIIF-96154-HEALTH AND BEHAVIOR INTERVENTION 18 44.000000 2200.0000 50.0000
EIIF-EIIF_NM-EI INDIVIDUAL SESSION BY NONMED PROF 13 28.000000 1400.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 3109 18264.75000 909649.0000 49.8035
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 506 1830.500000 91525.0000 50.0000
EPIC-99601-Early Steps Professional Development Fee 5316 30807.00000 430710.1000 13.9809
INTR-T1013-INTERPRETER 276 974.000000 49251.6000 50.5663
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 8693 52359.00000 627970.0000 11.9935
OCCT-97530-OT SESSION BY LICENSED OT 274 1167.000000 81322.6600 69.6852
OCCT-97530GT-OT SESSION BY LICENSED OT 19 42.250000 3022.3200 71.5342
OCCT-97530HM-OT SESSION BY OT ASST 75 418.825869 23824.8900 56.8850
OCCT-97530HMGT-OT SESSION BY OT ASST 1 3.000000 172.8000 57.6000
OCCT-97530TL-OT SESSION BY LICENSED OT 4 7.000000 503.7200 71.9600
PHY-97110-PT SESSION BY LICENSED PT 233 949.071151 66516.2200 70.0856
PHY-97110GT-PT SESSION BY LICENSED PT 8 17.000000 1061.5200 62.4424
PHY-97110HM-PT SESSION BY PT ASST 27 141.150103 7962.7100 56.4131
PHY-97110HMGT-PT SESSION BY LICENSED PT ASST 4 13.250000 762.6700 57.5600
PHY-97110TL-PT SESSION BY LICENSED PT 4 19.000000 1367.2400 71.9600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 566 2669.571427 188296.4400 70.5343
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 52 163.750000 11783.4500 71.9600
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 6 25.500000 1468.8000 57.6000
SPL-92507HMGT-SPL THERAPY SESSION BY SLP ASST 3 21.750000 1252.8000 57.6000
SPL-92507TL-SPL THERAPY SESSION BY LICENSED SLP 2 4.000000 287.8400 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 5.000000 69.8000 13.9600
TRAV-TRAVS-Travel by mile 4006 284501.0000 126445.4800 0.4444
Subtotal (Total Children Is Unduplicated) 14587 405812.3686 2976933.7700 7.3357
-----------------------------------------------------------------------------------------------------------------------
Total 443612.012083 4471384.8950 10.0795
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 21788
-----------------------------------------------------------------------------------------------------------------------
Center 01
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 1 1.500000 75.0000 75.0000
P 6318 19899.500000 104244.4500 104244.4500
D 146 426.500000 2907.2700 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 4621 12228.250000 73591.1200 73591.1200
329 349.000000 19475.3200 12.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 11415 32904.750000 200293.1600 177922.5700
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 3370 10643.750000 83941.4600 83759.9500
558 1086.250000 13973.2300 150.0000
Other 827 2397.000000 14423.4200 125.0000
---------------------------------------------------------
Total 4755 14127.000000 112338.1100 84034.9500
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 853 6320.500000 17949.7900 17949.7900
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 18 238.000000 484.1200 484.1200
T 0 0.000000 0.0000 0.0000
6580 40934.750000 149271.2700 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 7451 47493.250000 167705.1800 18433.9100
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 2513 9888.250000 218106.1100 218016.1100
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 8 22.000000 288.0000 225.0000
T 0 0.000000 0.0000 0.0000
1934 2407.750000 98022.7000 0.0000
Other 3 7.000000 372.8000 172.8000
---------------------------------------------------------
Total 4458 12325.000000 316789.6100 218413.9100
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 4891 51147.250000 160717.9400 160717.9400
D 6 3.000000 111.6000 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
3422 4243.250000 64627.2400 9614.7400
Other 1 0.750000 27.9000 0.0000
---------------------------------------------------------
Total 8320 55394.250000 225484.6800 170332.6800
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 8141 8263.000000 195155.9400 195155.9400
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 2 2.500000 93.0000 0.0000
5775 3949.250000 135319.0900 0.0000
Other 456 272.750000 10137.0000 0.0000
---------------------------------------------------------
Total 14374 12487.500000 340705.0300 195155.9400
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 10912 15162.750000 337432.4200 337426.4200
D 35 30.000000 1189.2000 0.0000
S 2 0.500000 18.6000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
6151 3437.802200 124520.2150 0.0000
Other 144 -389.500000 -4661.4000 -4680.0000
---------------------------------------------------------
Total 17244 18241.552200 458499.0350 332746.4200
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 9772 98412.500000 466866.2200 466866.2200
D 134 1347.000000 3860.9200 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
1027 5804.500000 39395.5700 0.0000
Other 23 41.000000 2664.2500 0.0000
---------------------------------------------------------
Total 10956 105605.000000 512786.9600 466866.2200
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 10118 21368.750000 568643.8700 568643.8700
D 9 12.250000 235.3000 0.0000
S 40 45.750000 1159.9300 100.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
5371 4653.500000 185061.6500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 15538 26080.250000 755100.7500 568743.8700
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 1342 3936.500000 112805.0200 112805.0200
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 26.250000 1256.5100 45.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 1349 3962.750000 114061.5300 112850.0200
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 0 0.000000 0.0000 0.0000
D 7 9.000000 637.2000 0.0000
S 147 87.750000 3143.4000 0.0000
H 0 0.000000 0.0000 0.0000
T 5289 30704.500000 75406.9700 73652.9700
2319 2722.250000 47055.6000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 7762 33523.500000 126243.1700 73652.9700
Center 53
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 1 0.250000 9.3000 0.0000
P 0 0.000000 0.0000 0.0000
D 148 106.000000 4435.8700 0.0000
S 13 6.750000 285.8600 0.0000
H 0 0.000000 0.0000 0.0000
T 1821 12255.500000 31919.5700 31910.2700
8851 8324.250000 164729.8800 0.0000
Other 22 14.750000 632.8500 0.0000
---------------------------------------------------------
Total 10856 20707.500000 202013.3300 31910.2700
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 0 0.000000 0.0000 0.0000
D 241 179.250000 7460.6400 0.0000
S 4 3.250000 24.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 2896 19288.250000 48900.9800 48490.5800
8982 10199.750000 180541.2400 0.0000
Other 43 34.500000 1283.4000 0.0000
---------------------------------------------------------
Total 12166 29705.000000 238210.2600 48490.5800
Center 55
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 2 0.500000 18.6000 0.0000
P 5466 10699.943313 139629.4100 139629.4100
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
5346 4134.266570 157246.5000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 10814 14834.709883 296894.5100 139629.4100
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 0 0.000000 0.0000 0.0000
D 148 173.000000 5546.9000 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 4969 6794.250000 139879.0000 139879.0000
7815 9247.750000 258634.8800 200.0000
Other 2 5.000000 198.8000 0.0000
---------------------------------------------------------
Total 12934 16220.000000 404259.5800 140079.0000