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: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 1 0.500000 18.5000 37.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 6 6.750000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 10 13.750000 508.7500 37.0000
Subtotal (Total Children Is Unduplicated) 17 21.000000 527.2500 25.1071
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Screening, Eval, and Assessment,Class #02
ASTE-ASTE-ASSISTIVE TECHNOLOGY EVAL 2 2.000000 97.0000 48.5000
AUDE-92552-PURE TONE AUDIOMETRY -AIR ONLY 27 32.000000 513.7200 16.0538
AUDE-92553-PURE TONE AUDIOMETRY AIR & BONE 1 1.000000 21.3500 21.3500
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 29 30.000000 383.6000 12.7867
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 33 36.000000 296.4000 8.2333
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 32 34.000000 865.6200 25.4594
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 8 8.000000 148.4000 18.5500
AUDE-92588-OTOACOUSTIC EMISSIONS (COMP) 4 4.000000 82.7200 20.6800
AUDE-V5010-ASSESSMENT FOR HEARING AID 1 1.000000 45.0000 45.0000
AUDE-V5090-DISPENSING FEE PER HEARING AID 2 3.000000 345.0000 115.0000
BEHV-H2014BA-BEHAVIOR ANALYSIS-ASSOCIATE 1 2.000000 97.5200 48.7600
EXIT-EXIT-EXIT ASSESSMENT 13 18.000000 900.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 34 61.378000 4453.3500 72.5561
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 14 27.500000 2062.5000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 5 7.500000 552.5000 73.6667
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 28 53.000000 3975.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 35 64.000000 3501.0000 54.7031
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 651 1175.371035 85842.3200 73.0342
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 260 453.146933 33269.1000 73.4179
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 210 347.333300 25169.4800 72.4649
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 597 1064.500000 58194.6100 54.6685
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 332 520.500000 39133.2200 75.1839
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 27 27.000000 8208.0000 304.0000
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 2 2.000000 386.0000 193.0000
NURS-T1001-NURSING ASSESSMENT 1 1.000000 50.0000 50.0000
OCTF-97168-OT RE-EVAL EST PLAN CARE 4 4.000000 204.2000 51.0500
OCTH-97165-OT EVAL LOW COMPLEXITY 3 3.000000 153.1500 51.0500
OCTH-97166-OT EVAL MODERATE COMPLEXITY 34 35.000000 1617.7700 46.2220
OCTH-97167-OT EVAL HIGH COMPLEXITY 42 42.000000 2124.1000 50.5738
PSTF-97164-PT RE-EVAL EST PLAN CARE 5 4.817800 174.2000 36.1576
PSTH-97161-PT EVAL LOW COMPLEXITY 3 3.000000 153.1500 51.0500
PSTH-97162-PT EVAL MODERATE COMPLEXITY 5 5.000000 255.2500 51.0500
PSTH-97163-PT EVAL HIGH COMPLEXITY 18 18.000000 918.9000 51.0500
SCREEN-T1023-SCREENING 18 20.000000 1000.0000 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 65 66.000000 3303.2500 50.0492
SPCH-92524-BEHAV & QUAL ANALYSIS OF VOICE AND RES 12 12.000000 612.6000 51.0500
SPCH-92610-EVAL OF ORAL,PHARYNGEAL SWALLOWING FUNC 1 1.000000 44.5500 44.5500
Subtotal (Total Children Is Unduplicated) 1448 4191.047068 279256.6300 66.6317
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 15 27.000000 15400.2700 570.3804
AUD-92593TS-AUDIOLOGY SERVICES (Biaural) 2 2.000000 61.8900 30.9450
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 46 49.500000 2475.0000 50.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 139 186.250000 9312.5000 50.0000
CONIP-CONIP-CONSULT, ITDS PHONE 1 0.500000 12.5000 25.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 60 72.000000 3600.0000 50.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 25 33.250000 1662.5000 50.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 73 84.500000 4225.0000 50.0000
CONSP-CONSP-CONSULT, SLP, PHONE 1 1.000000 25.0000 25.0000
COUN-H2019HR-INDIVIDUAL/FAMILY THERAPY 1 6.000000 439.9200 73.3200
EIIF-96154-HEALTH AND BEHAVIOR INTERVENTION 1 38.500000 1925.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 1234 7912.076000 392386.4400 49.5934
INTR-T1013-INTERPRETER 37 513.000000 21387.5000 41.6910
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 405 1240.000000 12400.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 417 2252.833503 155213.3814 68.8970
OCCT-97530HM-OT SESSION BY OT ASST 111 705.554638 39807.0400 56.4195
PHY-97110-PT SESSION BY LICENSED PT 417 2262.136223 148661.4844 65.7173
PHY-97110HM-PT SESSION BY PT ASST 26 161.499476 8988.4100 55.6560
SENS-V5050-IN EAR MONAURAL HEARING AID 1 2.000000 456.0000 228.0000
SENS-V5264-EARMOLD 4 8.000000 144.0000 18.0000
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 1098 6597.050731 445534.2077 67.5354
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 3 2.500000 136.8500 54.7400
SPL-92508-GROUP SPL SESSION PER CHILD 5 6.000000 83.2800 13.8800
TRAV-TRAVS-Travel by mile 319 15630.00000 6957.6600 0.4451
Subtotal (Total Children Is Unduplicated) 3073 37793.15057 1271295.8335 33.6383
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Total 42005.197639 1551079.7135 36.9259
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Number of Children (Unduplicated) With at Least One Service 4050
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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 1353 1375.500000 80167.7100 80167.7100
D 146 148.500000 8731.1000 0.0000
S 0 0.000000 0.0000 0.0000
H 410 468.000000 30766.1300 0.0000
T 1359 1460.500000 82992.2300 82956.5100
101 123.750000 7749.7400 0.0000
Other 21 26.500000 1721.1900 0.0000
---------------------------------------------------------
Total 3390 3602.750000 212128.1000 163124.2200
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 393 370.750000 26793.0300 26806.0300
0 0.000000 0.0000 0.0000
Other 1 2.000000 150.0000 0.0000
---------------------------------------------------------
Total 394 372.750000 26943.0300 26806.0300
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
3388 18447.250000 98849.3600 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 3388 18447.250000 98849.3600 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 123 331.500000 19811.7700 15816.2300
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
130 128.500000 16037.0000 0.0000
Other 82 190.500000 13252.4600 265.3700
---------------------------------------------------------
Total 335 650.500000 49101.2300 16081.6000
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 192 355.250000 24399.1900 24336.9500
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
1 4.000000 200.0000 200.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 193 359.250000 24599.1900 24536.9500
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 2584 2157.000000 119723.4900 119723.4900
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
1874 1755.000000 102444.8800 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 4458 3912.000000 222168.3700 119723.4900
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 288 715.000000 45831.1100 45831.1100
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
3 4.250000 157.2500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 291 719.250000 45988.3600 45831.1100
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 380 660.000000 42043.1600 41527.1800
D 7 9.000000 575.6400 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
242 674.500000 47373.6700 0.0000
Other 39 61.500000 4583.2500 0.0000
---------------------------------------------------------
Total 668 1405.000000 94575.7200 41527.1800
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 520 895.000000 54843.9000 54843.9000
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
627 1341.500000 90477.1800 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 1147 2236.500000 145321.0800 54843.9000
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 745 2567.250000 172509.2500 172509.1700
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
34 80.250000 5443.2600 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 779 2647.500000 177952.5100 172509.1700
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 71 89.500000 5827.7800 3216.6900
D 92 106.500000 5812.5400 51.0500
S 0 0.000000 0.0000 0.0000
H 119 194.250000 13080.1500 0.0000
T 767 1264.750000 74389.3800 67338.2200
278 472.500000 26647.0600 605.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 1327 2127.500000 125756.9100 71210.9600
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 35 33.306600 1740.3300 1209.4100
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 32 32.000000 2050.2400 2050.2400
T 14 14.000000 935.8400 935.8400
552 566.602578 30455.5814 0.0000
Other 125 153.000000 8827.5000 0.0000
---------------------------------------------------------
Total 758 798.909178 44009.4914 4195.4900
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 16 14.720000 739.0000 1119.0000
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 77 78.000000 4275.1600 2925.1600
T 80 83.500000 4590.1600 4590.1600
728 759.470000 44696.9344 34.9000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 901 935.690000 54301.2544 8669.2200
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 1399 1251.000000 84885.6400 84885.6400
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 9 18.000000 1350.0000 0.0000
T 0 0.000000 0.0000 0.0000
395 280.598461 19300.7977 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 1803 1549.598461 105536.4377 84885.6400
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 56 28.186600 1993.2600 1993.7100
D 0 0.000000 0.0000 0.0000
S 3 3.000000 150.0000 150.0000
H 0 0.000000 0.0000 0.0000
T 570 1713.563400 88266.3600 88302.0800
266 496.000000 33439.0500 24558.8000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 895 2240.750000 123848.6700 115004.5900