CMS/EIP Fiscal Report Statewide
Services beginning 10/01/2017 ending 12/31/2017 Date of Report:02/03/2018 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 4 2.500000 92.5000 37.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 7 8.500000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 77 156.250000 5781.2500 37.0000
Subtotal (Total Children Is Unduplicated) 81 167.250000 5873.7500 35.1196
-----------------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
ASTE-ASTE-ASSISTIVE TECHNOLOGY EVAL 2 3.000000 145.5000 48.5000
AUDE-92552-PURE TONE AUDIOMETRY -AIR ONLY 9 9.000000 161.2800 17.9200
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 9 9.000000 113.4900 12.6100
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 10 10.000000 82.6000 8.2600
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 9 9.000000 227.7900 25.3100
AUDE-92582-CONDITIONED PLAY AUDIOMETRY 1 1.000000 34.9700 34.9700
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 6 6.000000 111.3000 18.5500
AUDE-92588-OTOACOUSTIC EMISSIONS (COMP) 2 2.000000 41.3600 20.6800
AUDE-V5010-ASSESSMENT FOR HEARING AID 4 4.000000 180.0000 45.0000
AUDE-V5090-DISPENSING FEE PER HEARING AID 5 7.000000 805.0000 115.0000
EVAL-96111-DEVELOPMENTAL EVALUATION 1 2.000000 100.0000 50.0000
EXIT-EXIT-EXIT ASSESSMENT 5 5.250000 262.5000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 39 69.066667 4920.0000 71.2355
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 12 23.500000 1717.5000 73.0851
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 7 11.000000 825.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 23 35.500000 2650.0000 74.6479
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 30 54.000000 2858.5200 52.9356
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 498 910.000537 65662.9000 72.1570
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 191 342.968267 24593.8000 71.7087
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 179 290.966667 21415.8500 73.6024
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 513 908.000000 49667.5700 54.7000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 240 356.500000 26956.4800 75.6142
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 23 23.000000 6353.6600 276.2461
NUTR-97803-NUTRITIONAL EVAL, FOLLOW-UP 11 44.000000 2200.0000 50.0000
OCTF-97168-OT RE-EVAL EST PLAN CARE 1 1.000000 51.0500 51.0500
OCTH-97165-OT EVAL LOW COMPLEXITY 6 6.000000 306.3000 51.0500
OCTH-97166-OT EVAL MODERATE COMPLEXITY 13 15.000000 765.7500 51.0500
OCTH-97167-OT EVAL HIGH COMPLEXITY 23 24.000000 1225.2000 51.0500
PSTF-97164-PT RE-EVAL EST PLAN CARE 2 2.000000 102.1000 51.0500
PSTH-97161-PT EVAL LOW COMPLEXITY 1 1.000000 23.8600 23.8600
PSTH-97162-PT EVAL MODERATE COMPLEXITY 6 7.000000 306.3000 43.7571
PSTH-97163-PT EVAL HIGH COMPLEXITY 19 19.000000 933.3300 49.1226
SCREEN-T1023-SCREENING 11 11.000000 550.0000 50.0000
SPCH-92522-EVAL OF SPCH SOUND PROD 1 1.000000 51.0500 51.0500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 65 65.727522 3304.3400 50.2733
SPCH-92524-BEHAV & QUAL ANALYSIS OF
VOICE AND RES 8 8.000000 408.4000 51.0500
Subtotal (Total Children Is Unduplicated) 1147 3296.479660 220114.7500 66.7727
-----------------------------------------------------------------------------------------------------------------------
EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 5 5.000000 4688.1200 937.6240
AUD-92592TS-AUDIOLOGY SERVICES (Monaural) 1 1.000000 50.0000 50.0000
AUD-92593TS-AUDIOLOGY SERVICES (Biaural) 1 1.000000 11.8900 11.8900
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 39 39.500000 1975.0000 50.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 127 169.250000 8462.5000 50.0000
CONIP-CONIP-CONSULT, ITDS PHONE 1 1.000000 25.0000 25.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 37 44.000000 2200.0000 50.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 17 17.500000 875.0000 50.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 15 17.000000 850.0000 50.0000
COUN-H2019HR-INDIVIDUAL/FAMILY THERAPY 1 1.000000 73.3200 73.3200
DSTT-DSTT-DIRECT SERVICE COORDINATOR TRAVEL 17 20.250000 0.0000 0.0000
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 1 1.000000 25.0000 25.0000
EIIF-96154-HEALTH AND BEHAVIOR INTERVENTION 3 39.500000 1975.0000 50.0000
EIIF-EIIF_NM-EI INDIVIDUAL SESSION BY NONMED PROF 1 5.000000 207.0000 41.4000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 1101 6641.320000 329763.5000 49.6533
INTR-T1013-INTERPRETER 38 340.750000 10673.7500 31.3243
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 312 801.000000 8010.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 328 1552.965527 106509.7200 68.5847
OCCT-97530HM-OT SESSION BY OT ASST 93 450.815949 26015.4800 57.7075
PHY-97110-PT SESSION BY LICENSED PT 366 1893.407370 122763.2600 64.8372
PHY-97110HM-PT SESSION BY PT ASST 26 128.893896 7367.5700 57.1600
SENS-V5050-IN EAR MONAURAL HEARING AID 4 6.000000 1368.0000 228.0000
SENS-V5060-BEHIND EAR HEARING AID
1 1.000000 228.0000 228.0000
SENS-V5264-EARMOLD 7 11.000000 198.0000 18.0000
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 955 5269.093614 364797.2100 69.2334
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 2 15.500000 886.6000 57.2000
SPL-92508-GROUP SPL SESSION PER CHILD 10 92.000000 1001.7600 10.8887
TRAV-TRAVS-Travel by mile 278 12181.00000 5422.2000 0.4451
Subtotal (Total Children Is Unduplicated) 2669 29746.74636 1006422.8800 33.8330
-----------------------------------------------------------------------------------------------------------------------
Total 33210.476016 1232411.3800 37.1091
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 3471
-----------------------------------------------------------------------------------------------------------------------
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 1998 2019.750000 112170.8600 112170.8600
D 249 249.250000 14750.7900 0.0000
S 0 0.000000 0.0000 0.0000
H 264 286.000000 19628.0600 0.0000
T 68 66.750000 3975.4400 3975.4400
149 185.000000 12217.2500 0.0000
Other 19 30.000000 2090.4400 0.0000
---------------------------------------------------------
Total 2747 2836.750000 164832.8400 116146.3000
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 307 304.000000 21296.0900 21296.0900
0 0.000000 0.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 307 304.000000 21296.0900 21296.0900
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
2177 13828.000000 52698.6400 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 2177 13828.000000 52698.6400 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 50 112.500000 8300.8100 8300.8100
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 1 5.000000 357.2000 0.0000
T 0 0.000000 0.0000 0.0000
83 88.000000 11170.2500 0.0000
Other 81 197.500000 13076.0300 336.8100
---------------------------------------------------------
Total 215 403.000000 32904.2900 8637.6200
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 138 220.500000 15538.5900 15538.5900
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 138 220.500000 15538.5900 15538.5900
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 1993 1660.000000 90615.9600 90615.9600
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
1618 1538.000000 88984.3900 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 3611 3198.000000 179600.3500 90615.9600
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 127 239.260000 15964.1100 15964.1100
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 127 239.260000 15964.1100 15964.1100
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 444 928.000000 54695.2800 54840.4900
D 17 22.000000 1510.7100 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
314 747.250000 51486.1800 0.0000
Other 39 61.500000 4515.0000 0.0000
---------------------------------------------------------
Total 814 1758.750000 112207.1700 54840.4900
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 205 375.000000 22719.9900 22719.9900
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
465 1022.250000 68924.2900 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 670 1397.250000 91644.2800 22719.9900
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 276 949.500000 64757.1500 64757.1500
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
49 128.000000 8935.1700 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 325 1077.500000 73692.3200 64757.1500
Center 52
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 5 4.000000 148.0000 0.0000
P 81 101.250000 6806.6800 5093.6700
D 75 102.500000 5446.2500 0.0000
S 0 0.000000 0.0000 0.0000
H 95 155.750000 10315.6100 0.0000
T 822 1435.000000 87098.9600 78451.4900
250 397.500000 23230.0800 298.0500
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 1328 2196.000000 133045.5800 83843.2100
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 32 35.084190 2106.8698 842.6200
D 4 5.000000 295.7500 0.0000
S 0 0.000000 0.0000 0.0000
H 34 35.000000 2211.2400 2211.2400
T 10 10.000000 564.3200 564.3200
749 798.915810 42832.0102 0.0000
Other 17 22.500000 1326.6300 0.0000
---------------------------------------------------------
Total 846 906.500000 49336.8200 3618.1800
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 93 93.250000 5010.2700 5010.2700
T 22 23.000000 1279.2000 1279.2000
904 924.360000 49337.6400 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 1019 1040.610000 55627.1100 6289.4700
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 725 682.632800 47105.7100 47105.7100
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 3 4.666667 350.0000 0.0000
T 412 373.250000 25590.3500 25590.3500
837 698.943149 47426.5400 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 1977 1759.492616 120472.6000 72696.0600
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 20 10.863400 755.6900 755.6900
D 0 0.000000 0.0000 0.0000
S 24 14.000000 915.4500 915.4500
H 0 0.000000 0.0000 0.0000
T 429 1393.500000 71521.2900 71521.2900
275 626.500000 40358.1600 38828.4100
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 748 2044.863400 113550.5900 112020.8400