CMS/EIP Fiscal Report Statewide
Services beginning 01/01/2018 ending 03/31/2018 Date of Report:05/05/2018 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 6 6.750000 249.7500 37.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 1 1.500000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 30 42.750000 1600.2500 37.4327
Subtotal (Total Children Is Unduplicated) 35 51.000000 1850.0000 36.2745
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Screening, Eval, and Assessment,Class #02
AUDE-92552-PURE TONE AUDIOMETRY -AIR ONLY 18 18.000000 322.5600 17.9200
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 18 18.000000 226.9800 12.6100
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 21 22.000000 175.2200 7.9645
AUDE-92568-ACOUSTIC REFLEX TESTING (MEMR) 2 2.000000 18.1200 9.0600
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 23 23.000000 582.1300 25.3100
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 6 6.000000 111.3000 18.5500
AUDE-92588-OTOACOUSTIC EMISSIONS (COMP) 1 1.000000 20.6800 20.6800
AUDE-V5010-ASSESSMENT FOR HEARING AID 1 1.000000 45.0000 45.0000
AUDE-V5090-DISPENSING FEE PER HEARING AID 1 2.000000 230.0000 115.0000
EVAL-96111-DEVELOPMENTAL EVALUATION 5 13.000000 650.0000 50.0000
EXIT-EXIT-EXIT ASSESSMENT 6 7.000000 350.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 33 66.500000 4875.0000 73.3083
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 15 26.500000 1987.5000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 5 10.000000 750.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 33 51.000000 4419.2100 86.6512
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 38 74.000000 4090.5000 55.2770
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 559 1033.848568 75358.9000 72.8916
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 227 413.778400 30591.3300 73.9317
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 197 324.388100 24042.9000 74.1177
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 521 947.520000 51755.3600 54.6219
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 307 481.500000 38366.5500 79.6813
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 26 26.000000 6786.2500 261.0096
MED-99204-OUTPATIENT VISIT, NEW, 45 MINS 1 1.000000 507.0000 507.0000
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 4 4.000000 661.6600 165.4150
NUTR-97803-NUTRITIONAL EVAL, FOLLOW-UP 4 9.000000 450.0000 50.0000
OCTF-97168-OT RE-EVAL EST PLAN CARE 3 2.770029 141.4100 51.0500
OCTH-97165-OT EVAL LOW COMPLEXITY 2 2.000000 62.1000 31.0500
OCTH-97166-OT EVAL MODERATE COMPLEXITY 13 13.000000 652.6000 50.2000
OCTH-97167-OT EVAL HIGH COMPLEXITY 36 36.418413 1819.1600 49.9517
PSTF-97164-PT RE-EVAL EST PLAN CARE 3 3.000000 153.1500 51.0500
PSTH-97161-PT EVAL LOW COMPLEXITY 2 2.000000 102.1000 51.0500
PSTH-97162-PT EVAL MODERATE COMPLEXITY 5 6.000000 354.2000 59.0333
PSTH-97163-PT EVAL HIGH COMPLEXITY 26 26.000000 1312.3000 50.4731
SCREEN-T1023-SCREENING 4 4.000000 200.0000 50.0000
SPCH-92521-EVAL OF SPEECH FLUENCY 1 1.000000 51.0500 51.0500
SPCH-92522-EVAL OF SPCH SOUND PROD 2 2.000000 102.1000 51.0500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 93 96.000000 4824.7500 50.2578
SPCH-92524-BEHAV & QUAL ANALYSIS OF
VOICE AND RES 8 8.000000 408.4000 51.0500
SPCH-92610-EVAL OF ORAL,PHARYNGEAL SWALLOWING FUNC 1 1.000000 44.5500 44.5500
Subtotal (Total Children Is Unduplicated) 1300 3785.223510 257602.0200 68.0546
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 10 49.000000 10979.3400 224.0682
AUD-92592TS-AUDIOLOGY SERVICES (Monaural) 1 1.000000 50.0000 50.0000
AUD-92593TS-AUDIOLOGY SERVICES (Biaural) 1 1.000000 50.0000 50.0000
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 5 6.000000 300.0000 50.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 7 5.750000 287.5000 50.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 6 6.000000 300.0000 50.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 2 2.000000 100.0000 50.0000
DSTT-DSTT-DIRECT SERVICE COORDINATOR TRAVEL 3 2.750000 0.0000 0.0000
EIIF-96154-HEALTH AND BEHAVIOR INTERVENTION 1 42.000000 2100.0000 50.0000
EIIF-EIIF_NM-EI INDIVIDUAL SESSION BY NONMED PROF 1 1.000000 50.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 1056 6969.068600 347335.9100 49.8396
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 3 5.000000 50.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 376 1887.370335 129885.3803 68.8182
OCCT-97530HM-OT SESSION BY OT ASST 102 731.848100 41707.8100 56.9897
PHY-97110-PT SESSION BY LICENSED PT 375 2085.466390 142820.3100 68.4836
PHY-97110HM-PT SESSION BY PT ASST 25 137.873690 7880.8600 57.1600
SENS-V5050-IN EAR MONAURAL HEARING AID 1 2.000000 456.0000 228.0000
SENS-V5264-EARMOLD 6 11.000000 198.0000 18.0000
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 1011 6117.333845 422981.6000 69.1448
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 6 22.000000 1258.4000 57.2000
SPL-92508-GROUP SPL SESSION PER CHILD 1 2.500000 34.7000 13.8800
TRAV-TRAVS-Travel by mile 1 12.000000 5.3400 0.4450
Subtotal (Total Children Is Unduplicated) 2454 18099.96096 1108831.1503 61.2615
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Total 21936.184470 1368283.1703 62.3756
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Number of Children (Unduplicated) With at Least One Service 3332
-----------------------------------------------------------------------------------------------------------------------
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 2037 2069.000000 118557.2500 118557.2500
D 177 185.000000 10307.3600 0.0000
S 0 0.000000 0.0000 0.0000
H 414 461.250000 31702.0400 0.0000
T 93 93.250000 5458.6600 4946.7700
62 77.250000 4803.2600 0.0000
Other 16 22.000000 1359.2500 0.0000
---------------------------------------------------------
Total 2799 2907.750000 172187.8200 123504.0200
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 408 378.750000 25749.7200 25331.5100
47 45.500000 3118.1900 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 455 424.250000 28867.9100 25331.5100
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
11 13.000000 908.2900 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 11 13.000000 908.2900 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 63 98.000000 10301.2900 10301.2900
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 2 7.500000 535.8000 0.0000
T 0 0.000000 0.0000 0.0000
113 121.500000 14220.2500 0.0000
Other 86 214.000000 14253.6400 142.9000
---------------------------------------------------------
Total 264 441.000000 39310.9800 10444.1900
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 152 240.500000 16565.5900 16566.3100
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
0 0.000000 0.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 152 240.500000 16565.5900 16566.3100
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 2103 1773.250000 98399.1100 98399.1100
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
1735 1572.000000 95300.8400 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 3838 3345.250000 193699.9500 98399.1100
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 127 261.000000 17013.9600 17013.9600
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
2 3.000000 151.1400 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 129 264.000000 17165.1000 17013.9600
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 456 866.000000 55376.8500 55447.4500
D 13 18.500000 1327.1400 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
261 702.500000 48901.8100 74.4000
Other 62 94.000000 6933.0000 0.0000
---------------------------------------------------------
Total 792 1681.000000 112538.8000 55521.8500
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 329 522.500000 32012.2800 31840.8000
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 1442.750000 96556.7800 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 994 1965.250000 128569.0600 31840.8000
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 712 2285.000000 153207.0200 153207.7400
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
95 222.500000 15093.1700 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 807 2507.500000 168300.1900 153207.7400
Center 52
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 1 3.000000 150.0000 150.0000
P 40 50.750000 3527.0000 2071.9700
D 53 64.750000 3408.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 54 78.750000 5229.8400 0.0000
T 775 1224.750000 75974.5100 68047.5700
358 618.000000 37824.8900 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 1281 2040.000000 126114.2400 70269.5400
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 65 71.728600 3956.4300 1569.5300
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 72 72.250000 4538.1000 4538.1000
T 29 31.500000 1716.0400 1716.0400
679 726.650000 38706.5000 0.0000
Other 61 67.500000 3679.0000 0.0000
---------------------------------------------------------
Total 906 969.628600 52596.0700 7823.6700
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 94.500000 5136.4400 4786.4400
T 78 85.000000 4836.3500 4836.3500
681 737.210000 41403.8900 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 852 916.710000 51376.6800 9622.7900
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 1251 1140.911926 78747.4100 78747.4100
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 1 2.000000 150.0000 0.0000
T 0 0.000000 0.0000 0.0000
785 662.183944 44663.7103 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 2037 1805.095870 123561.1203 78747.4100
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 89 47.396700 3324.8400 3324.8400
D 0 0.000000 0.0000 0.0000
S 95 50.000000 3424.3400 3424.3400
H 0 0.000000 0.0000 0.0000
T 545 1730.853300 90093.8500 89786.6500
260 587.000000 39678.3400 39547.3400
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 989 2415.250000 136521.3700 136083.1700