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: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 6 1.750000 65.1000 37.2000
TCM-T1017TL-TARGETED CASE MANAGEMENT 71 127.500000 4743.0000 37.2000
Subtotal (Total Children Is Unduplicated) 74 129.250000 4808.1000 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 27 50.487200 3786.5400 75.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 5 9.000000 636.0000 70.6667
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 8 18.000000 1350.0000 75.0000
IPDEF-T1024TLTSGT-F/U PHYC AND DEV EVAL BY EI PROF 6 10.000000 750.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 9 15.000000 832.5000 55.5000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 7 13.500000 749.2500 55.5000
IPDEI-IPDEI_NM-INITIAL PSYCH & DEV EVAL BY NON-MED PR 2 3.000000 166.5000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 418 813.613201 60225.4200 74.0222
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 249 461.663200 34587.2400 74.9188
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 175 320.572533 23738.0800 74.0490
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 140 261.880000 19678.5000 75.1432
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 136 233.099800 17139.4350 73.5283
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 85 155.000000 11625.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 363 660.500000 36696.7500 55.5590
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 268 484.500000 26969.2500 55.6641
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 143 273.968000 20472.6000 74.7262
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 119 205.000000 15375.0000 75.0000
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 11 11.000000 3344.0000 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) 1467 4375.606467 297086.8150 67.8961
-----------------------------------------------------------------------------------------------------------------------
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:Program Patients
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 18510.620489 1213020.9870 65.5311
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 3734
-----------------------------------------------------------------------------------------------------------------------
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 1352 1376.250000 75551.4000 75551.4000
D 50 50.000000 2763.5200 0.0000
S 1 1.000000 71.9600 0.0000
H 363 456.000000 30766.2400 0.0000
T 910 917.500000 48907.6000 49032.0200
125 150.000000 9669.1300 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 2801 2950.750000 167729.8500 124583.4200
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 474 327.250000 23969.5300 23912.2700
46 28.000000 2014.8800 0.0000
Other 1 0.750000 53.9700 53.9700
---------------------------------------------------------
Total 521 356.000000 26038.3800 23966.2400
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 18 19.500000 1200.3400 1200.3400
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
226 284.500000 18267.9400 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 247 307.000000 19618.2800 1350.3400
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
85 118.500000 11298.3600 0.0000
Other 136 292.000000 20521.0700 555.1300
---------------------------------------------------------
Total 257 485.000000 36677.9900 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 65 62.500000 3846.7100 3846.7100
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 72 69.500000 4350.4300 4350.4300
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 283 237.250000 15126.3600 15126.3600
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
611 761.750000 50483.8700 0.0000
Other 24 14.750000 548.7000 0.0000
---------------------------------------------------------
Total 918 1013.750000 66158.9300 15126.3600
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 766 769.197800 54033.1350 54033.1300
D 8 16.000000 1200.0000 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
105 189.750000 13711.5000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 889 994.947800 70444.6350 54033.1300
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 610 1990.500000 138358.9400 138346.9800
D 7 22.000000 1511.1600 0.0000
S 0 0.000000 0.0000 0.0000
H 119 186.500000 12594.6800 12594.6800
T 0 0.000000 0.0000 0.0000
178 474.250000 33488.4600 0.0000
Other 11 19.000000 1152.0000 0.0000
---------------------------------------------------------
Total 925 2692.250000 187105.2400 150941.6600
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
1375 2204.000000 151925.9900 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 2648 4418.750000 302160.7900 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 82 92.500000 6177.3000 4987.5500
D 79 80.750000 5900.4500 0.0000
S 0 0.000000 0.0000 0.0000
H 97 125.750000 9156.2000 0.0000
T 1103 1178.750000 66729.0600 59513.6500
481 531.750000 32391.4500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 1842 2009.500000 120354.4600 64501.2000
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 119 122.440000 7989.1200 0.0000
S 0 0.000000 0.0000 0.0000
H 92 95.000000 6806.4700 0.0000
T 54 55.500000 4726.2100 4726.2100
363 387.500000 26600.6200 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 639 667.120000 46772.5000 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 118 126.000000 8659.0000 0.0000
T 346 362.140000 19595.5500 19595.5500
461 487.610000 31980.5200 0.0000
Other 4 4.000000 287.8400 0.0000
---------------------------------------------------------
Total 1000 1050.130000 65425.1700 20205.6900
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 238 245.750000 16708.8400 16708.8400
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 41 77.500000 5801.8600 0.0000
T 0 0.000000 0.0000 0.0000
447 446.422689 30361.5520 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 726 769.672689 52872.2520 16708.8400
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
446 601.104219 39497.7400 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 520 683.250000 44999.4200 3984.7400