CMS/EIP Fiscal Report Statewide
Services beginning 04/01/2018 ending 06/30/2018 Date of Report:08/10/2018 Page: 1
List order: No List
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 12493 14515.75000 536917.2500 36.9886
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 9004 9034.500000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 23369 73494.25000 2718464.5000 36.9888
Subtotal (Total Children Is Unduplicated) 24501 97044.50000 3255381.7500 33.5452
-----------------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
ASTE-ASTE-ASSISTIVE TECHNOLOGY EVAL 29 31.000000 1503.5000 48.5000
AUDE-92552-PURE TONE AUDIOMETRY -AIR ONLY 113 123.000000 2144.4400 17.4345
AUDE-92553-PURE TONE AUDIOMETRY AIR & BONE 5 5.000000 106.7500 21.3500
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 123 130.000000 1644.6000 12.6508
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 151 160.000000 1320.6400 8.2540
AUDE-92568-ACOUSTIC REFLEX TESTING (MEMR) 1 1.000000 9.0600 9.0600
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 166 175.000000 4434.3300 25.3390
AUDE-92585-AUD EVOKED RESPONSE (COMP) 3 3.000000 231.3900 77.1300
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 81 82.000000 1521.1000 18.5500
AUDE-92588-OTOACOUSTIC EMISSIONS (COMP) 25 27.000000 558.3600 20.6800
AUDE-V5010-ASSESSMENT FOR HEARING AID 4 5.000000 225.0000 45.0000
AUDE-V5090-DISPENSING FEE PER HEARING AID 5 8.000000 920.0000 115.0000
BEHV-H2014BA-BEHAVIOR ANALYSIS-ASSOCIATE 3 16.000000 780.1600 48.7600
EVAL-96111-DEVELOPMENTAL EVALUATION 114 125.500000 6275.0000 50.0000
EXIT-EXIT-EXIT ASSESSMENT 874 1459.500000 72812.5000 49.8887
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 182 314.500000 23433.9400 74.5117
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 89 143.500000 10762.5000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 30 50.500000 3777.5000 74.8020
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 124 227.500000 17062.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 240 397.000000 21954.7500 55.3016
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 3036 5061.000000 376423.1800 74.3772
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 1304 2115.000100 157883.2900 74.6493
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 888 1468.500300 109140.4800 74.3210
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 3648 5880.500000 324951.6600 55.2592
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 1567 2497.000000 187094.3800 74.9277
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 132 132.000000 13830.7500 104.7784
MED-99204-OUTPATIENT VISIT, NEW, 45 MINS 11 11.000000 832.9200 75.7200
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 13 13.000000 678.7100 52.2085
MED-99214-OUTPATIENT VISIT, EST, 25 MINS 1 1.000000 41.4600 41.4600
NURS-T1001-NURSING ASSESSMENT 1 1.000000 50.0000 50.0000
NUTR-97802-NUTRITIONAL EVAL, INITIAL 1 12.000000 600.0000 50.0000
NUTR-97803-NUTRITIONAL EVAL, FOLLOW-UP 10 56.000000 2800.0000 50.0000
OCTF-97168-OT RE-EVAL EST PLAN CARE 45 45.000000 2244.4700 49.8771
OCTH-97165-OT EVAL LOW COMPLEXITY 16 16.000000 816.8000 51.0500
OCTH-97166-OT EVAL MODERATE COMPLEXITY 84 87.000000 4232.3700 48.6479
OCTH-97167-OT EVAL HIGH COMPLEXITY 143 145.000000 7382.2500 50.9121
PSTF-97164-PT RE-EVAL EST PLAN CARE 21 21.000000 976.8800 46.5181
PSTH-97161-PT EVAL LOW COMPLEXITY 5 5.000000 255.2500 51.0500
PSTH-97162-PT EVAL MODERATE COMPLEXITY 27 27.000000 1378.3500 51.0500
PSTH-97163-PT EVAL HIGH COMPLEXITY 89 89.000000 4499.4100 50.5552
SCREEN-T1023-SCREENING 187 209.000000 10450.0000 50.0000
SPCH-92521-EVAL OF SPEECH FLUENCY 4 4.000000 204.2000 51.0500
SPCH-92522-EVAL OF SPCH SOUND PROD 5 5.000000 255.2500 51.0500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 243 245.000000 12316.5500 50.2716
SPCH-92524-BEHAV & QUAL ANALYSIS OF VOICE AND RES 22 22.000000 1123.1000 51.0500
SPCH-92610-EVAL OF ORAL,PHARYNGEAL SWALLOWING FUNC 6 6.000000 267.3000 44.5500
Subtotal (Total Children Is Unduplicated) 7352 21658.00040 1392207.0300 64.2814
-----------------------------------------------------------------------------------------------------------------------
EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 45 83.000000 31915.1000 384.5193
AUD-92592TS-AUDIOLOGY SERVICES (Monaural) 1 1.000000 50.0000 50.0000
AUD-92593TS-AUDIOLOGY SERVICES (Biaural) 3 3.000000 87.6300 29.2100
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 1638 1968.250000 97750.0000 49.6634
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 64 47.250000 1181.2500 25.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 2337 4767.000000 238187.5000 49.9659
CONIP-CONIP-CONSULT, ITDS PHONE 180 213.500000 5318.7500 24.9122
CONOF-CONOF-CONSULT, OT, FACE TO FACE 518 917.000000 45825.0000 49.9727
CONOP-CONOP-CONSULT, OT, PHONE 37 56.750000 1418.7500 25.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 384 622.500000 31087.5000 49.9398
CONPP-CONPP-CONSULT, PT, PHONE 15 8.750000 218.7500 25.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 1339 1792.500000 89587.5000 49.9791
CONSP-CONSP-CONSULT, SLP, PHONE 85 141.250000 3531.2500 25.0000
COUN-H2019HR-INDIVIDUAL/FAMILY THERAPY 25 57.000000 4179.2400 73.3200
DSTT-DSTT-DIRECT SERVICE COORDINATOR TRAVEL 2162 4974.500000 0.0000 0.0000
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 92 758.000000 18950.0000 25.0000
EIIF-96154-HEALTH AND BEHAVIOR INTERVENTION 1 38.500000 1925.0000 50.0000
EIIF-EIIF_NM-EI INDIVIDUAL SESSION BY NONMED PROF 10 64.000000 3200.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 9688 76140.00000 3799215.0000 49.8978
INTR-T1013-INTERPRETER 513 2367.250000 108513.3600 45.8394
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 14484 132481.0000 1321448.8600 9.9746
OCCT-97530-OT SESSION BY LICENSED OT 1246 7200.960491 503895.3314 69.9761
OCCT-97530HM-OT SESSION BY OT ASST 432 2814.500200 160368.1800 56.9793
PHY-97110-PT SESSION BY LICENSED PT 1270 7733.755600 529474.8744 68.4628
CMS/EIP Fiscal Report Statewide
Services beginning 04/01/2018 ending 06/30/2018 Date of Report:08/10/2018 Page: 2
List order: No List
Eligibility Filter:Program Patients
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
PHY-97110HM-PT SESSION BY PT ASST 219 1809.250000 103173.8300 57.0257
SENS-V5014-*HEARING AID REPAIR BY MANUFACTURER 1 1.000000 50.0000 50.0000
SENS-V5050-IN EAR MONAURAL HEARING AID 2 4.000000 912.0000 228.0000
SENS-V5060-BEHIND EAR HEARING AID 1 1.000000 228.0000 228.0000
SENS-V5264-EARMOLD 7 13.000000 234.0000 18.0000
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 2709 18407.24781 1277765.7077 69.4164
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 94 496.000000 28365.0500 57.1876
SPL-92508-GROUP SPL SESSION PER CHILD 38 280.500000 3893.3400 13.8800
TRAV-TRAVS-Travel by mile 6775 680130.0000 300559.8000 0.4419
Subtotal (Total Children Is Unduplicated) 17694 946393.2141 8712510.5535 9.2060
-----------------------------------------------------------------------------------------------------------------------
Total 1065095.714499 13360099.3335 12.5436
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 27194
-----------------------------------------------------------------------------------------------------------------------
Center 01
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 43 35.000000 2186.5600 0.0000
U 0 0.000000 0.0000 0.0000
B 8738 5857.250000 237647.9200 0.0000
P 12973 51520.000000 265367.7900 265367.7900
D 847 2287.750000 33712.6900 0.0000
S 143 133.250000 5446.8500 0.0000
H 417 475.000000 31223.3300 0.0000
T 12152 52737.250000 249841.6300 249685.7800
6820 4553.250000 144638.2600 10.0000
Other 415 539.250000 32239.9600 0.0000
---------------------------------------------------------
Total 42548 118138.000000 1002304.9900 515063.5700
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 5739 15732.000000 137204.9000 137112.3600
1 1.000000 73.3200 76.2000
Other 5953 17988.250000 131257.2100 0.0000
---------------------------------------------------------
Total 11693 33721.250000 268535.4300 137188.5600
Center 03
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 4 2.000000 74.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 3605 2584.500000 107380.4500 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 1 0.250000 9.2500 0.0000
26016 127921.750000 597060.4000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 29626 130508.500000 704524.1000 0.0000
Center 04
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 25 53.750000 1988.7500 0.0000
U 0 0.000000 0.0000 0.0000
B 2247 3789.750000 140548.0500 0.0000
P 5484 19161.750000 394498.9000 386713.8500
D 1 1.000000 75.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 2896 12261.500000 624671.5800 741.6000
T 0 0.000000 0.0000 0.0000
4414 4584.500000 198013.7300 0.0000
Other 92 216.500000 14646.8400 1122.8800
---------------------------------------------------------
Total 15159 40068.750000 1374442.8500 388578.3300
Center 05
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 1 0.500000 18.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 2988 1979.750000 78895.7500 0.0000
P 6285 78975.750000 223814.0200 222370.8700
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
3509 2525.250000 57227.8000 765.8000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 12783 83481.250000 359956.0700 223136.6700
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 11928 11412.250000 260841.4700 260841.4700
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
19990 15019.000000 494253.4500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 31918 26431.250000 755094.9200 260841.4700
Center 07
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 1 2.000000 74.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 37 61.500000 4327.5000 0.0000
P 9440 18508.750000 481515.1200 481515.1200
D 193 143.500000 5713.2500 0.0000
S 32 56.500000 3882.5000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
7458 4851.500000 145745.7600 196.4600
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 17161 23623.750000 641258.1300 481711.5800
Center 09
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 439 480.750000 18351.7500 0.0000
P 23311 171420.500000 1047313.7900 1074051.4900
D 7 9.000000 575.6400 0.0000
S 0 0.000000 0.0000 0.0000
H 610 920.250000 47688.5000 0.0000
T 0 0.000000 0.0000 0.0000
2798 10964.000000 448373.1200 12.5000
Other 255 425.500000 31195.2500 50.0000
---------------------------------------------------------
Total 27420 184220.000000 1593498.0500 1074113.9900
Center 10
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 42 31.250000 1156.2500 0.0000
U 0 0.000000 0.0000 0.0000
B 10313 8572.750000 364196.5000 0.0000
P 11774 34672.500000 910359.8600 910359.8600
D 59 37.000000 1315.0000 20.0000
S 1 0.250000 6.2500 6.2500
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
11010 19000.500000 892964.3700 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 33199 62314.250000 2169998.2300 910386.1100
Center 51
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 848 629.750000 25171.7500 0.0000
P 3784 24295.000000 355340.9700 354926.5700
D 6 4.250000 195.2500 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
3930 5869.000000 297919.9300 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 8568 30798.000000 678627.9000 354926.5700
Center 52
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 163 114.000000 4277.5000 0.0000
P 3426 3221.000000 154725.4300 150513.5400
D 115 131.250000 7147.3600 51.0500
S 9 20.000000 1285.0000 0.0000
H 131 205.500000 13886.2800 40.0000
T 7261 61032.500000 248888.8400 237872.6100
4432 4304.250000 174228.0500 1820.1200
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 15537 69028.500000 604438.4600 390297.3200
Center 53
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 2 1.500000 68.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 17 13.750000 656.7500 9.2500
P 4198 3881.056600 175761.3300 175175.6600
D 0 0.000000 0.0000 0.0000
S 29 25.750000 1055.7500 0.0000
H 2661 20421.851483 36536.7500 36536.7500
T 2119 13640.500000 27283.3500 27283.3500
17762 36952.551908 344583.1814 0.0000
Other 129 157.000000 9027.5000 0.0000
---------------------------------------------------------
Total 26917 75093.959991 594973.1114 239005.0100
Center 54
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 2 3.500000 186.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 3079 2694.250000 113321.2500 0.0000
P 3272 2772.470000 122109.7500 122489.7500
D 188 153.750000 6549.5000 0.0000
S 121 132.500000 6343.5000 6278.7500
H 4952 28783.340000 64372.4700 63022.4700
T 5331 32883.130000 69168.4500 69168.4500
20959 47741.060000 451802.1444 34.9000
Other 1 0.250000 9.2500 0.0000
---------------------------------------------------------
Total 37905 115164.250000 833862.8144 260994.3200
Center 55
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 250 201.750000 7464.7500 0.0000
P 17183 25380.680047 487583.4400 487686.6900
D 0 0.000000 0.0000 0.0000
S 2 1.524000 114.3000 0.0000
H 10 20.000000 1500.0000 0.0000
T 0 0.000000 0.0000 0.0000
10025 7714.800461 400269.0877 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 27470 33318.754508 896931.5777 487686.6900
Center 57
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 843 926.500000 37095.7500 0.0000
P 56 28.186600 1993.2600 1993.7100
D 18 17.750000 769.7500 0.0000
S 31 50.000000 1480.0800 1480.0800
H 6 4.500000 249.7500 0.0000
T 4289 26675.563400 299496.9100 299052.0500
6227 11273.750000 538445.8100 367911.1700
Other 61 209.000000 2121.3900 2121.3900
---------------------------------------------------------
Total 11531 39185.250000 881652.7000 672558.4000