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
Payclass Filters:GR
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 12491 14507.75000 536621.2500 36.9886
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 8860 8938.500000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 8185 25475.25000 942205.5000 36.9851
Subtotal (Total Children Is Unduplicated) 19071 48921.50000 1478826.7500 30.2286
-----------------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
ASTE-ASTE-ASSISTIVE TECHNOLOGY EVAL 27 29.000000 1406.5000 48.5000
AUDE-92552-PURE TONE AUDIOMETRY -AIR ONLY 86 91.000000 1630.7200 17.9200
AUDE-92553-PURE TONE AUDIOMETRY AIR & BONE 4 4.000000 85.4000 21.3500
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 94 100.000000 1261.0000 12.6100
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 118 124.000000 1024.2400 8.2600
AUDE-92568-ACOUSTIC REFLEX TESTING (MEMR) 1 1.000000 9.0600 9.0600
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 134 141.000000 3568.7100 25.3100
AUDE-92585-AUD EVOKED RESPONSE (COMP) 2 2.000000 154.2600 77.1300
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 73 74.000000 1372.7000 18.5500
AUDE-92588-OTOACOUSTIC EMISSIONS (COMP) 21 23.000000 475.6400 20.6800
AUDE-V5010-ASSESSMENT FOR HEARING AID 3 4.000000 180.0000 45.0000
AUDE-V5090-DISPENSING FEE PER HEARING AID 3 5.000000 575.0000 115.0000
BEHV-H2014BA-BEHAVIOR ANALYSIS-ASSOCIATE 2 14.000000 682.6400 48.7600
EVAL-96111-DEVELOPMENTAL EVALUATION 114 125.500000 6275.0000 50.0000
EXIT-EXIT-EXIT ASSESSMENT 857 1433.500000 71512.5000 49.8866
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 36 56.622000 4243.0900 74.9371
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 19 22.500000 1687.5000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 5 7.500000 562.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 22 32.500000 2437.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 57 82.000000 4523.2500 55.1616
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 634 993.942965 73899.7500 74.3501
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 240 365.353167 27377.5400 74.9345
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 190 310.667000 23278.1600 74.9296
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 897 1297.500000 71480.3000 55.0908
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 358 558.500000 41686.1600 74.6395
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 78 78.000000 4176.9000 53.5500
MED-99204-OUTPATIENT VISIT, NEW, 45 MINS 10 10.000000 757.2000 75.7200
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 4 4.000000 106.4400 26.6100
MED-99214-OUTPATIENT VISIT, EST, 25 MINS 1 1.000000 41.4600 41.4600
NUTR-97802-NUTRITIONAL EVAL, INITIAL 1 3.000000 150.0000 50.0000
NUTR-97803-NUTRITIONAL EVAL, FOLLOW-UP 8 18.000000 900.0000 50.0000
OCTF-97168-OT RE-EVAL EST PLAN CARE 18 18.000000 866.1200 48.1178
OCTH-97165-OT EVAL LOW COMPLEXITY 10 10.000000 510.5000 51.0500
OCTH-97166-OT EVAL MODERATE COMPLEXITY 30 31.000000 1582.5500 51.0500
OCTH-97167-OT EVAL HIGH COMPLEXITY 59 59.000000 3011.9500 51.0500
PSTF-97164-PT RE-EVAL EST PLAN CARE 7 6.182200 292.1800 47.2615
PSTH-97161-PT EVAL LOW COMPLEXITY 1 1.000000 51.0500 51.0500
PSTH-97162-PT EVAL MODERATE COMPLEXITY 12 12.000000 612.6000 51.0500
PSTH-97163-PT EVAL HIGH COMPLEXITY 30 30.000000 1487.4600 49.5820
SCREEN-T1023-SCREENING 85 96.000000 4800.0000 50.0000
SPCH-92521-EVAL OF SPEECH FLUENCY 3 3.000000 153.1500 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 128 127.000000 6365.2000 50.1197
SPCH-92524-BEHAV & QUAL ANALYSIS OF VOICE AND RES 8 8.000000 408.4000 51.0500
SPCH-92610-EVAL OF ORAL,PHARYNGEAL SWALLOWING FUNC 3 3.000000 133.6500 44.5500
Subtotal (Total Children Is Unduplicated) 2936 6418.267332 367898.0300 57.3205
-----------------------------------------------------------------------------------------------------------------------
EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 30 55.000000 16152.2800 293.6778
AUD-92592TS-AUDIOLOGY SERVICES (Monaural) 1 1.000000 50.0000 50.0000
AUD-92593TS-AUDIOLOGY SERVICES (Biaural) 1 1.000000 25.7400 25.7400
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 1555 1827.500000 90712.5000 49.6375
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 43 28.750000 718.7500 25.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 2303 4563.750000 228025.0000 49.9644
CONIP-CONIP-CONSULT, ITDS PHONE 179 213.000000 5306.2500 24.9120
CONOF-CONOF-CONSULT, OT, FACE TO FACE 500 831.000000 41525.0000 49.9699
CONOP-CONOP-CONSULT, OT, PHONE 37 56.750000 1418.7500 25.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 366 565.250000 28225.0000 49.9337
CONPP-CONPP-CONSULT, PT, PHONE 15 8.250000 206.2500 25.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 1307 1692.500000 84587.5000 49.9778
CONSP-CONSP-CONSULT, SLP, PHONE 83 138.250000 3456.2500 25.0000
COUN-H2019HR-INDIVIDUAL/FAMILY THERAPY 22 47.000000 3446.0400 73.3200
DSTT-DSTT-DIRECT SERVICE COORDINATOR TRAVEL 2162 4974.500000 0.0000 0.0000
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 54 242.000000 6050.0000 25.0000
EIIF-EIIF_NM-EI INDIVIDUAL SESSION BY NONMED PROF 10 64.000000 3200.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 2930 19882.17400 990369.5600 49.8119
INTR-T1013-INTERPRETER 498 1841.250000 86607.8600 47.0375
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 14449 131168.0000 1308318.8600 9.9744
OCCT-97530-OT SESSION BY LICENSED OT 568 2744.626988 191824.4700 69.8909
OCCT-97530HM-OT SESSION BY OT ASST 141 754.445562 43083.7400 57.1065
PHY-97110-PT SESSION BY LICENSED PT 600 3026.869377 209008.0500 69.0509
PHY-97110HM-PT SESSION BY PT ASST 60 420.500524 24035.8100 57.1600
SENS-V5014-*HEARING AID REPAIR BY MANUFACTURER 1 1.000000 50.0000 50.0000
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
Payclass Filters:GR
Eligibility Filter:Program Patients
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
SENS-V5050-IN EAR MONAURAL HEARING AID 1 2.000000 456.0000 228.0000
SENS-V5060-BEHIND EAR HEARING AID 1 1.000000 228.0000 228.0000
SENS-V5264-EARMOLD 3 5.000000 90.0000 18.0000
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 1187 6825.197077 477372.0800 69.9426
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 28 98.000000 5605.6000 57.2000
SPL-92508-GROUP SPL SESSION PER CHILD 20 230.000000 3192.4000 13.8800
TRAV-TRAVS-Travel by mile 6418 585504.0000 258729.3400 0.4419
Subtotal (Total Children Is Unduplicated) 16925 767813.5635 4112077.0800 5.3556
-----------------------------------------------------------------------------------------------------------------------
Total 823153.330860 5958801.8600 7.2390
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 24651
-----------------------------------------------------------------------------------------------------------------------
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 11609 50134.000000 184581.5800 184581.5800
D 399 1839.250000 6793.0600 0.0000
S 3 2.250000 83.2500 0.0000
H 6 6.000000 407.2000 0.0000
T 10757 51243.500000 164826.2600 164873.8200
6660 4380.000000 134005.1600 10.0000
Other 3 3.000000 171.4400 0.0000
---------------------------------------------------------
Total 29437 107608.000000 490867.9500 349465.4000
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 5345 15359.250000 110261.8700 110306.3300
1 1.000000 73.3200 76.2000
Other 3989 16463.750000 64545.4600 0.0000
---------------------------------------------------------
Total 9335 31824.000000 174880.6500 110382.5300
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
22268 109064.000000 470910.7500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 22268 109064.000000 470910.7500 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 4308 17506.750000 310644.8700 310644.8700
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 23 76.000000 3015.6200 491.6000
T 0 0.000000 0.0000 0.0000
3368 3244.500000 131262.9700 0.0000
Other 10 26.000000 1394.3800 857.5100
---------------------------------------------------------
Total 7709 20853.250000 446317.8400 311993.9800
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 6073 78589.500000 197747.8200 196554.9100
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
3506 2517.750000 56898.3000 565.8000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 9579 81107.250000 254646.1200 197120.7100
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 9344 9255.250000 141117.9800 141117.9800
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
12621 9100.750000 214090.5700 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 21965 18356.000000 355208.5500 141117.9800
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 4344 13757.500000 270243.9600 270243.9600
D 193 143.500000 5713.2500 0.0000
S 17 34.000000 2550.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
7420 4808.750000 143676.5100 196.4600
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 11974 18743.750000 422183.7200 270440.4200
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 14970 86452.250000 563486.0500 563486.7300
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
41 145.000000 2291.7000 0.0000
Other 2 3.000000 166.5000 0.0000
---------------------------------------------------------
Total 15013 86600.250000 565944.2500 563486.7300
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 11252 33773.500000 855315.9600 855315.9600
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
6933 5301.250000 170331.7500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 18245 39112.000000 1026968.9600 855342.2100
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 3036 21711.750000 182327.4000 182327.4000
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
2626 2113.000000 73749.5300 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 5668 23829.000000 256272.1800 182327.4000
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 0 0.000000 0.0000 0.0000
D 8 6.750000 337.5000 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 6491 59761.750000 174211.5900 170267.5200
3357 2219.250000 52040.0300 44.0300
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 9856 61987.750000 226589.1200 170311.5500
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 0 0.000000 0.0000 0.0000
D 0 0.000000 0.0000 0.0000
S 19 17.750000 656.7500 0.0000
H 2629 20389.851483 34486.5100 34486.5100
T 2105 13626.500000 26347.5100 26347.5100
15111 34204.449330 202296.3500 0.0000
Other 4 4.000000 200.0000 0.0000
---------------------------------------------------------
Total 19868 68242.550813 263987.1200 60834.0200
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 185 151.250000 6431.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 4875 28705.340000 60097.3100 60097.3100
T 5251 32799.630000 64578.2900 64578.2900
16571 43174.340000 208904.3700 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 26882 104830.560000 340010.9700 124675.6000
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 12023 20812.518047 264477.6500 264477.6500
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
4919 2787.452000 97284.1500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 16943 23601.970047 361911.8000 264477.6500
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 0 0.000000 0.0000 0.0000
D 18 17.750000 769.7500 0.0000
S 27 43.000000 1130.0800 1130.0800
H 0 0.000000 0.0000 0.0000
T 3719 24962.000000 211230.5500 210749.9700
2317 2370.250000 88971.5000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 6081 27393.000000 302101.8800 211880.0500