CMS/EIP Fiscal Report Statewide
Services beginning 04/01/2017 ending 06/30/2017 Date of Report:08/05/2017 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 1 0.250000 9.2500 37.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 5 5.250000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 29 58.250000 2090.5000 35.8884
Subtotal (Total Children Is Unduplicated) 35 63.750000 2099.7500 32.9373
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Screening, Eval, and Assessment,Class #02
AUDE-92552-PURE TONE AUDIOMETRY -AIR ONLY 1 1.000000 14.8700 14.8700
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 2 2.000000 25.2200 12.6100
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 12 12.000000 91.0500 7.5875
AUDE-92568-ACOUSTIC REFLEX TESTING (MEMR) 1 1.000000 9.0600 9.0600
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 11 11.000000 278.4100 25.3100
AUDE-92585-AUD EVOKED RESPONSE (COMP) 1 1.000000 77.1300 77.1300
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 4 4.000000 74.2000 18.5500
EVAL-96111-DEVELOPMENTAL EVALUATION 6 10.407400 520.3700 50.0000
EXIT-EXIT-EXIT ASSESSMENT 1 1.000000 50.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 28 55.500000 3782.5000 68.1532
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 9 21.000000 1405.0000 66.9048
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 7 11.500000 862.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 26 38.000000 2856.2700 75.1650
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 29 52.000000 2886.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 473 818.879241 60616.7431 74.0240
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 223 374.739997 27511.6200 73.4152
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 163 268.299100 19943.7725 74.3341
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 536 957.000000 52433.0600 54.7890
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 322 482.248999 37903.2756 78.5969
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 16 16.000000 4692.7700 293.2981
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 1 1.000000 193.0000 193.0000
NUTR-97802-NUTRITIONAL EVAL, INITIAL 1 2.000000 100.0000 50.0000
NUTR-97803-NUTRITIONAL EVAL, FOLLOW-UP 16 69.000000 3450.0000 50.0000
OCTF-97168-OT RE-EVAL EST PLAN CARE 1 1.000000 51.0500 51.0500
OCTH-97165-OT EVAL LOW COMPLEXITY 4 4.000000 204.2000 51.0500
OCTH-97166-OT EVAL MODERATE COMPLEXITY 9 9.000000 459.4500 51.0500
OCTH-97167-OT EVAL HIGH COMPLEXITY 30 29.543976 1501.4100 50.8195
PSTH-97161-PT EVAL LOW COMPLEXITY 1 1.000000 51.0500 51.0500
PSTH-97162-PT EVAL MODERATE COMPLEXITY 12 13.844858 634.9000 45.8582
PSTH-97163-PT EVAL HIGH COMPLEXITY 15 15.000000 765.7500 51.0500
SCREEN-T1023-SCREENING 13 13.000000 650.0000 50.0000
SENS-V5014TS-HEARING AID REPAIR IN-OFFICE 1 1.000000 15.0000 15.0000
SPCH-92521-EVAL OF SPEECH FLUENCY 1 1.000000 51.0500 51.0500
SPCH-92522-EVAL OF SPCH SOUND PROD 1 1.000000 51.0500 51.0500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 69 70.000000 3503.5400 50.0506
SPCH-92524-BEHAV & QUAL ANALYSIS OF
VOICE AND RES 9 9.000000 459.4500 51.0500
Subtotal (Total Children Is Unduplicated) 1206 3378.963571 228174.7212 67.5280
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 9 28.000000 5372.9100 191.8896
AUD-92593TS-AUDIOLOGY SERVICES (Biaural) 1 1.000000 50.0000 50.0000
AUDE-V5160-DISPENSING FEE BINAURAL 1 1.000000 230.0000 230.0000
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 1 1.000000 50.0000 50.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 1 0.500000 25.0000 50.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 1 1.000000 50.0000 50.0000
COUN-H2019HR-INDIVIDUAL/FAMILY THERAPY 2 5.000000 366.6000 73.3200
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 5 11.000000 275.0000 25.0000
EIIF-96154-HEALTH AND BEHAVIOR INTERVENTION 3 119.000000 5950.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 766 3961.000000 197790.6000 49.9345
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 2 2.000000 20.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 288 1260.203509 84851.9914 67.3320
OCCT-97530HM-OT SESSION BY OT ASST 112 601.410178 34222.1300 56.9031
PHY-97110-PT SESSION BY LICENSED PT 330 1502.342551 100140.9282 66.6565
PHY-97110HM-PT SESSION BY PT ASST 25 122.570200 6748.2400 55.0561
SENS-V5050-IN EAR MONAURAL HEARING AID 1 1.000000 228.0000 228.0000
SENS-V5140-BEHIND EAR BINAURAL HEARING AID
1 1.000000 456.0000 456.0000
SENS-V5264-EARMOLD 8 14.000000 252.0000 18.0000
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 767 4075.622511 282635.0661 69.3477
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 9 53.000000 2745.6000 51.8038
SPL-92508-GROUP SPL SESSION PER CHILD 5 7.500000 104.1000 13.8800
TRAV-TRAVS-Travel by mile 2 98.000000 43.6200 0.4451
Subtotal (Total Children Is Unduplicated) 1924 11867.14895 722607.7857 60.8914
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Total 15309.862520 952882.2569 62.2398
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Number of Children (Unduplicated) With at Least One Service 2819
-----------------------------------------------------------------------------------------------------------------------
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 1131 1170.750000 68622.3100 68622.3100
D 83 90.500000 4838.9800 0.0000
S 0 0.000000 0.0000 0.0000
H 88 113.500000 7986.6000 0.0000
T 307 310.250000 17986.4600 17986.4600
30 38.000000 2505.6700 0.0000
Other 18 27.000000 1761.7500 0.0000
---------------------------------------------------------
Total 1657 1750.000000 103701.7700 86608.7700
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 2 2.000000 60.2200 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 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 2 2.000000 60.2200 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
12 11.500000 604.7700 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 12 11.500000 604.7700 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 194 439.500000 29837.7100 29837.7100
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 1 2.500000 178.6000 0.0000
T 0 0.000000 0.0000 0.0000
96 91.500000 10350.7100 0.0000
Other 70 163.500000 11189.2800 945.2200
---------------------------------------------------------
Total 361 697.000000 51556.3000 30782.9300
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 96 184.750000 12775.3700 12775.3700
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 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 96 184.750000 12775.3700 12775.3700
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 845 679.000000 37683.3000 37683.3000
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
1184 1133.000000 69613.3000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 2029 1812.000000 107296.6000 37683.3000
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 258 497.250000 32100.5700 32100.5700
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
13 13.250000 572.1300 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 271 510.500000 32672.7000 32100.5700
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 438 817.000000 48834.5300 48822.5700
D 11 15.000000 949.5000 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
432 1026.000000 70014.8400 0.0000
Other 15 22.500000 1658.2500 0.0000
---------------------------------------------------------
Total 896 1880.500000 121457.1200 48822.5700
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
665 1401.000000 94976.5300 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 665 1401.000000 94976.5300 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 301 1081.750000 70769.5800 70769.5800
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
36 104.000000 7396.1000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 337 1185.750000 78165.6800 70769.5800
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 11 12.500000 664.3600 547.6800
D 70 96.000000 5100.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 203 256.750000 17162.9900 0.0000
T 450 781.500000 50123.3700 44716.8200
349 499.000000 29771.4500 214.3200
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 1083 1645.750000 102822.1700 45478.8200
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 42 39.450000 1923.7500 1188.7500
D 10 12.000000 661.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 70 71.649800 3653.9800 3653.9800
849 914.649199 47470.1656 0.0000
Other 29 27.250000 1412.5000 0.0000
---------------------------------------------------------
Total 1000 1064.998999 55121.3956 4842.7300
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 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 119 124.500000 7006.8500 7006.8500
759 921.240000 46913.5400 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 878 1045.740000 53920.3900 7006.8500
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 444 419.220044 28787.6400 28787.6400
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 8 16.000000 1150.0000 0.0000
T 0 0.000000 0.0000 0.0000
1022 824.403477 55997.9913 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 1474 1259.623521 85935.6313 28787.6400
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 30 33.273900 2271.2600 2271.2600
D 0 0.000000 0.0000 0.0000
S 5 7.726100 467.2400 467.2400
H 0 0.000000 0.0000 0.0000
T 126 375.500000 20601.5800 20601.5800
216 442.250000 28475.5300 27890.2800
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 377 858.750000 51815.6100 51230.3600