CMS/EIP Fiscal Report Statewide
Services beginning 07/01/2017 ending 09/30/2017 Date of Report:11/05/2017 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
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 2 0.750000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 75 149.250000 5522.2500 37.0000
Subtotal (Total Children Is Unduplicated) 76 150.000000 5522.2500 36.8150
-----------------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
AUDE-92552-PURE TONE AUDIOMETRY -AIR ONLY 4 4.000000 71.6800 17.9200
AUDE-92553-PURE TONE AUDIOMETRY AIR & BONE 1 1.000000 21.3500 21.3500
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 6 6.000000 75.6600 12.6100
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 6 6.000000 49.5600 8.2600
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 6 6.000000 151.8600 25.3100
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 3 3.000000 55.6500 18.5500
AUDE-V5090-DISPENSING FEE PER HEARING AID 1 1.000000 115.0000 115.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 21 36.220800 2716.5600 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 19 35.500000 2539.0200 71.5217
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 5 9.500000 712.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 22 32.509777 2553.1733 78.5356
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 23 40.500000 2125.2700 52.4758
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 477 829.755572 61019.1500 73.5387
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 216 378.325234 27868.0800 73.6617
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 167 291.000000 21453.2000 73.7223
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 435 758.500000 41230.3500 54.3577
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 241 372.499970 27382.7378 73.5107
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 10 10.000000 3040.0000 304.0000
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 2 2.000000 386.0000 193.0000
NUTR-97803-NUTRITIONAL EVAL, FOLLOW-UP 15 72.000000 3600.0000 50.0000
OCTF-97168-OT RE-EVAL EST PLAN CARE 3 2.312576 118.0600 51.0513
OCTH-97165-OT EVAL LOW COMPLEXITY 4 4.000000 174.2000 43.5500
OCTH-97166-OT EVAL MODERATE COMPLEXITY 10 10.000000 495.1700 49.5170
OCTH-97167-OT EVAL HIGH COMPLEXITY 31 31.000000 1582.5500 51.0500
PSTF-97164-PT RE-EVAL EST PLAN CARE 2 2.000000 62.1000 31.0500
PSTH-97162-PT EVAL MODERATE COMPLEXITY 7 7.000000 307.3500 43.9071
PSTH-97163-PT EVAL HIGH COMPLEXITY 17 16.979432 866.8000 51.0500
SCREEN-T1023-SCREENING 8 9.000000 450.0000 50.0000
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 54 55.000000 2807.7500 51.0500
SPCH-92524-BEHAV & QUAL ANALYSIS OF
VOICE AND RES 7 6.979500 356.3000 51.0495
Subtotal (Total Children Is Unduplicated) 1057 3041.582861 204489.1811 67.2312
-----------------------------------------------------------------------------------------------------------------------
EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 8 38.000000 10105.6000 265.9368
AUD-92593TS-AUDIOLOGY SERVICES (Biaural) 2 2.000000 100.0000 50.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 1 1.000000 50.0000 50.0000
CONIP-CONIP-CONSULT, ITDS PHONE 1 0.500000 12.5000 25.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 1 1.000000 50.0000 50.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 1 1.000000 50.0000 50.0000
COUN-H2019HR-INDIVIDUAL/FAMILY THERAPY 4 6.000000 439.9200 73.3200
DSTT-DSTT-DIRECT SERVICE COORDINATOR TRAVEL 6 4.250000 0.0000 0.0000
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 3 6.000000 150.0000 25.0000
EIIF-96154-HEALTH AND BEHAVIOR INTERVENTION 4 136.000000 6800.0000 50.0000
EIIF-EIIF_NM-EI INDIVIDUAL SESSION BY NONMED PROF 1 18.000000 745.2000 41.4000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 910 5098.400000 254255.6800 49.8697
INTR-T1013-INTERPRETER 2 4.500000 225.0000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 5 8.000000 80.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 298 1317.310399 90946.5298 69.0396
OCCT-97530HM-OT SESSION BY OT ASST 100 580.050350 33018.0800 56.9228
PHY-97110-PT SESSION BY LICENSED PT 330 1450.663013 93835.2936 64.6844
PHY-97110HM-PT SESSION BY PT ASST 27 99.048720 5690.1874 57.4484
SENS-V5050-IN EAR MONAURAL HEARING AID 1 1.000000 228.0000 228.0000
SENS-V5264-EARMOLD 2 4.000000 72.0000 18.0000
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 882 7720.431844 324968.9000 42.0921
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 7 30.000000 1661.0000 55.3667
SPL-92508-GROUP SPL SESSION PER CHILD 7 24.000000 333.1200 13.8800
TRAV-TRAVS-Travel by mile 3 123.000000 54.7400 0.4450
Subtotal (Total Children Is Unduplicated) 2139 16674.15433 823871.7508 49.4101
-----------------------------------------------------------------------------------------------------------------------
Total 19865.737187 1033883.1819 52.0435
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 2900
-----------------------------------------------------------------------------------------------------------------------
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 1569 1604.000000 90839.2200 90839.2200
D 216 219.000000 12521.9600 0.0000
S 0 0.000000 0.0000 0.0000
H 162 188.000000 13146.6900 0.0000
T 191 200.500000 11177.0900 11177.0800
38 46.000000 2869.8100 0.0000
Other 7 10.000000 577.7600 0.0000
---------------------------------------------------------
Total 2183 2267.500000 131132.5300 102016.3000
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 161 158.000000 10191.7600 10191.7600
17 9.500000 646.5200 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 178 167.500000 10838.2800 10191.7600
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
4 3.250000 150.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 4 3.250000 150.0000 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 67 139.500000 8466.9000 8466.9000
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 2 7.500000 464.6000 0.0000
T 0 0.000000 0.0000 0.0000
106 101.500000 9918.6000 0.0000
Other 64 117.500000 7680.2900 351.1300
---------------------------------------------------------
Total 239 366.000000 26530.3900 8818.0300
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 108 170.750000 11376.2400 11951.4000
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 108 170.750000 11376.2400 11951.4000
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 1465 1226.000000 67840.1200 67840.1200
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
1352 1293.250000 77221.4600 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 2817 2519.250000 145061.5800 67840.1200
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 202 331.000000 20943.3100 20943.3100
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
24 22.500000 934.3300 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 226 353.500000 21877.6400 20943.3100
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 447 856.500000 51227.2100 51381.6900
D 21 27.500000 1861.2300 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
395 879.000000 61118.9300 0.0000
Other 37 58.500000 4387.5000 0.0000
---------------------------------------------------------
Total 900 1821.500000 118594.8700 51381.6900
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 64 96.500000 5220.3900 5220.3900
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
458 1047.000000 74364.1500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 522 1143.500000 79584.5400 5220.3900
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 315 4133.000000 74159.2900 74159.2900
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
47 130.500000 8991.1900 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 362 4263.500000 83150.4800 74159.2900
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 23 26.250000 1464.0600 1147.9100
D 67 83.000000 4366.8300 40.0000
S 0 0.000000 0.0000 0.0000
H 136 188.500000 12262.3500 0.0000
T 791 1269.500000 80240.4900 71049.3300
256 451.000000 26944.0100 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 1273 2018.250000 125277.7400 72237.2400
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 18 17.906640 821.2202 610.2200
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 13 13.000000 650.0000 650.0000
T 12 13.000000 700.0000 700.0000
700 763.853107 41128.3809 0.0000
Other 30 30.500000 1470.3800 0.0000
---------------------------------------------------------
Total 773 838.259747 44769.9811 1960.2200
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 94 95.866800 5373.3442 5373.3400
T 15 14.500000 832.2000 832.2000
678 817.723198 39485.5392 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 787 928.089998 45691.0834 6205.5400
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 676 640.750000 44389.9700 44389.9700
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 7 14.000000 1050.0000 0.0000
T 0 0.000000 0.0000 0.0000
936 839.387442 57587.4674 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 1619 1494.137442 103027.4374 44389.9700
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 49 24.500000 1750.2800 1750.2800
D 0 0.000000 0.0000 0.0000
S 20 10.500000 728.6800 728.6800
H 0 0.000000 0.0000 0.0000
T 260 887.000000 46671.0400 46671.0400
337 588.750000 37670.3900 35571.3500
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 666 1510.750000 86820.3900 84721.3500