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:MED
Eligibility Filter:Program Patients
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 10804 31959.50000 1188626.1500 37.1916
Subtotal (Total Children Is Unduplicated) 10804 31959.50000 1188626.1500 37.1916
-----------------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
AACIS-92597-AAC INTIAL EVAL BY LICENSED SLP 1 1.000000 103.3600 103.3600
AACIS-92597TL-AAC INTIAL EVAL BY LICENSED SLP 2 2.000000 206.7200 103.3600
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 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 53 97.500000 7312.5000 75.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 32 57.500000 4312.5000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 14 27.000000 2025.0000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 15 27.000000 2025.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 14 24.000000 1800.0000 75.0000
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 10 19.000000 1425.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 21 39.000000 2850.0000 73.0769
IPDEF-T1024TLTSGT-F/U PHYC AND DEV EVAL BY EI PROF 10 17.000000 1275.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 56 105.500000 5894.2500 55.8697
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 39 69.000000 3829.5000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 736 1337.000000 100312.5000 75.0280
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 479 851.500000 63833.2500 74.9656
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 207 377.000000 28312.5000 75.0995
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 331 586.000000 43950.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 231 385.000000 29062.5000 75.4870
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 159 291.500000 21937.5000 75.2573
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 869 1541.500000 85408.9500 55.4064
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 741 1305.000000 72468.0000 55.5310
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 264 469.000000 35088.3000 74.8151
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 247 422.000000 31650.0000 75.0000
OCTF-97168-OT RE-EVAL EST PLAN CARE 2 2.000000 102.8200 51.4100
OCTH-97165-OT EVAL LOW COMPLEXITY 12 12.000000 616.9200 51.4100
OCTH-97165TL-OT EVAL LOW COMPLEXITY 1 1.000000 51.4100 51.4100
OCTH-97166-OT EVAL MODERATE COMPLEXITY 11 11.000000 565.5100 51.4100
OCTH-97166TLGT-OT EVAL MODERATE COMPLEXITY 2 2.000000 123.3700 61.6850
OCTH-97167-OT EVAL HIGH COMPLEXITY 9 9.000000 462.6900 51.4100
OCTH-97167GT-OT EVAL HIGH COMPLEXITY 1 1.000000 51.4100 51.4100
PSTF-97164-PT RE-EVAL EST PLAN CARE 2 2.000000 102.8200 51.4100
PSTH-97161-PT EVAL LOW COMPLEXITY 10 10.000000 514.1000 51.4100
PSTH-97161GT-PT EVAL LOW COMPLEXITY 1 1.000000 51.4100 51.4100
PSTH-97162-PT EVAL MODERATE COMPLEXITY 1 1.000000 51.4100 51.4100
PSTH-97162GT-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 7 7.000000 359.8700 51.4100
PSTH-97163GT-PT EVAL HIGH COMPLEXITY 1 1.000000 51.4100 51.4100
SCREEN-T1023-SCREENING 16 16.000000 900.0000 56.2500
SPCH-92521-EVAL OF SPEECH FLUENCY 19 19.000000 976.7900 51.4100
SPCH-92521GT-EVAL OF SPEECH FLUENCY 4 8.000000 411.2800 51.4100
SPCH-92521TLGT-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-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 15 15.000000 822.5600 54.8373
SPCH-92523TL-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 7 7.000000 359.8700 51.4100
SPCH-92523TLGT-EVAL OF SPCH SOUND PROD; EVAL LANG COM 1 1.000000 51.4100 51.4100
SPCH-92610TL-EVAL OF ORAL,PHARYNGEAL SWALLOWING FUNC 1 1.000000 51.4100 51.4100
SPL-92526-TREATMENT OF SWALLOWING DYSFUNCTION 1 12.000000 863.5200 71.9600
SPL-92526TL-TREATMENT OF SWALLOWING DYSFUNCTION 6 21.000000 1079.6100 51.4100
Subtotal (Total Children Is Unduplicated) 2619 8220.000000 554002.5300 67.3969
-----------------------------------------------------------------------------------------------------------------------
EI Services,Class #03
AACFIT-92609-AAC FITTING, ADJUST, TRAINING VISIT 1 1.000000 42.4100 42.4100
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 7 18.000000 450.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 4568 27532.75000 1376912.5000 50.0100
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 872 3317.250000 165691.5000 49.9485
OCCT-97530-OT SESSION BY LICENSED OT 364 1652.000000 118877.9800 71.9600
OCCT-97530GT-OT SESSION BY LICENSED OT 23 61.000000 4389.5600 71.9600
OCCT-97530HM-OT SESSION BY OT ASST 140 761.500000 43888.8000 57.6347
OCCT-97530HMGT-OT SESSION BY OT ASST 8 21.750000 1223.9800 56.2749
OCCT-97530TL-OT SESSION BY LICENSED OT 132 418.980000 30148.4200 71.9567
OCCT-97530TLGT-OT SESSION BY LICENSED OT 46 115.500000 8275.4000 71.6485
OCCT-97530TLHM-OT SESSION BY OT ASST 8 16.000000 921.6000 57.6000
PHY-97110-PT SESSION BY LICENSED PT 329 1328.750000 95412.7700 71.8064
PHY-97110GT-PT SESSION BY LICENSED PT 10 19.000000 1367.2400 71.9600
PHY-97110HM-PT SESSION BY PT ASST 75 413.250000 23779.1100 57.5417
PHY-97110HMGT-PT SESSION BY LICENSED PT ASST 9 25.500000 1467.7800 57.5600
PHY-97110TL-PT SESSION BY LICENSED PT 122 523.750000 37689.0500 71.9600
PHY-97110TLGT-PT SESSION BY LICENSED PT 28 31.500000 2266.7400 71.9600
PHY-97110TLHM-PT SESSION BY PT ASST 6 22.000000 1266.3200 57.5600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 511 2748.150000 197756.7900 71.9600
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:MED
Eligibility Filter:Program Patients
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 46 170.730000 12285.3500 71.9578
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 18 84.250000 4795.2000 56.9163
SPL-92507TL-SPL THERAPY SESSION BY LICENSED SLP 135 488.140000 35125.2200 71.9573
SPL-92507TLGT-SPL THERAPY SESSION BY LICENSED SLP 27 55.250000 3975.7900 71.9600
Subtotal (Total Children Is Unduplicated) 6154 39826.00000 2168009.5100 54.4370
-----------------------------------------------------------------------------------------------------------------------
Total 80005.500000 3910638.1900 48.8796
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 12946
-----------------------------------------------------------------------------------------------------------------------
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 52 52.250000 2670.9600 0.0000
S 14 15.000000 1044.3800 0.0000
H 640 864.000000 57574.7200 57574.7200
T 0 0.000000 0.0000 0.0000
0 0.000000 0.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 706 931.250000 61290.0600 57574.7200
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 483 364.000000 15840.4600 0.0000
---------------------------------------------------------
Total 483 364.000000 15840.4600 0.0000
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 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
1697 1272.000000 48828.5500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 1697 1272.000000 48828.5500 0.0000
Center 04
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 89 159.500000 6597.4500 0.0000
U 0 0.000000 0.0000 0.0000
B 1379 2309.250000 90570.0000 0.0000
P 674 1089.250000 42123.4600 41388.0500
D 22 38.750000 1479.3000 0.0000
S 1 0.250000 9.3000 0.0000
H 1513 5796.500000 291985.4300 0.0000
T 0 0.000000 0.0000 0.0000
290 367.250000 23642.3500 0.0000
Other 15 21.000000 781.2000 0.0000
---------------------------------------------------------
Total 3983 9781.750000 457188.4900 41388.0500
Center 05
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 27 18.500000 688.2000 0.0000
U 0 0.000000 0.0000 0.0000
B 2281 1451.500000 53995.8000 27369.9800
P 0 0.000000 0.0000 0.0000
D 2 1.250000 46.5000 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 67 52.250000 1943.7000 0.0000
---------------------------------------------------------
Total 2377 1523.500000 56674.2000 27369.9800
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
9393 8605.750000 403909.8300 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 9393 8605.750000 403909.8300 0.0000
Center 07
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 59 38.750000 1478.1000 0.0000
U 0 0.000000 0.0000 0.0000
B 746 642.500000 30023.3000 0.0000
P 1806 1516.250000 68521.9500 68484.7500
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
3 2.500000 93.0000 0.0000
Other 49 24.250000 902.1000 0.0000
---------------------------------------------------------
Total 2663 2224.250000 101018.4500 68484.7500
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 0 0.000000 0.0000 0.0000
D 6 16.000000 909.8000 0.0000
S 0 0.000000 0.0000 0.0000
H 1996 2201.000000 92140.2000 92140.2000
T 0 0.000000 0.0000 0.0000
1608 4912.250000 260279.5600 130.2000
Other 105 196.250000 13266.3000 0.0000
---------------------------------------------------------
Total 3715 7325.500000 366595.8600 92270.4000
Center 10
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 47 32.750000 1218.3000 0.0000
U 0 0.000000 0.0000 0.0000
B 8885 8002.000000 346828.6500 0.0000
P 17 25.500000 1528.9000 132.0000
D 15 11.750000 449.9000 0.0000
S 18 30.750000 1754.0100 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
5153 10407.750000 590981.9500 0.0000
Other 404 293.250000 11021.1000 0.0000
---------------------------------------------------------
Total 14539 18803.750000 953782.8100 132.0000
Center 51
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 1 1.000000 55.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 10 9.000000 527.2500 0.0000
P 1 2.000000 100.0000 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
310 975.750000 58985.9600 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 322 987.750000 59668.7100 0.0000
Center 52
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 44 41.250000 2184.6600 0.0000
U 0 0.000000 0.0000 0.0000
B 642 667.500000 34253.8400 174.2600
P 1357 1366.250000 65144.7600 64980.4200
D 0 0.000000 0.0000 0.0000
S 214 208.000000 8701.8000 210.0200
H 0 0.000000 0.0000 0.0000
T 1 0.500000 18.6000 0.0000
888 893.750000 50473.5100 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 3146 3177.250000 160777.1700 65364.7000
Center 53
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 27 23.250000 903.3000 0.0000
U 0 0.000000 0.0000 0.0000
B 486 451.500000 24329.7000 0.0000
P 2528 2392.000000 119122.6000 119094.4000
D 18 17.250000 902.0000 0.0000
S 133 145.380000 5835.0900 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
963 985.000000 53947.1500 0.0000
Other 147 121.250000 5780.9000 203.7000
---------------------------------------------------------
Total 4302 4135.630000 210820.7400 119298.1000
Center 54
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 33 29.000000 1113.5600 0.0000
U 0 0.000000 0.0000 0.0000
B 627 608.750000 27687.8900 0.0000
P 3735 3494.250000 159558.6100 159555.1100
D 1 0.500000 18.6000 0.0000
S 20 19.640000 1355.0300 0.0000
H 8 7.480000 503.9600 0.0000
T 0 0.000000 0.0000 0.0000
1318 1409.750000 74568.7600 0.0000
Other 108 90.250000 4324.3800 0.0000
---------------------------------------------------------
Total 5850 5659.620000 269130.7900 159555.1100
Center 55
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 1806 1833.000000 82203.0400 0.0000
P 1177 1145.500000 47371.5000 45595.5000
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
2304 2409.250000 147755.5800 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 5287 5387.750000 277330.1200 45595.5000
Center 57
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 1739 2640.500000 116664.0000 0.0000
P 16 23.500000 1538.2500 1538.2500
D 0 0.000000 0.0000 0.0000
S 6 9.000000 587.2500 0.0000
H 270 401.750000 14945.1000 14945.1000
T 1 1.500000 83.2500 83.2500
4822 6529.750000 325789.4000 0.0000
Other 214 219.750000 8174.7000 0.0000
---------------------------------------------------------
Total 7068 9825.750000 467781.9500 16566.6000