CMS/EIP Fiscal Report Statewide
Services beginning 10/01/2018 ending 12/31/2018 Date of Report:02/06/2019 Page: 1
List order: No List
Payclass Filters:GR
Eligibility Filter:Part C (excluding not eligible)
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
CASE-CASE-NON-TCM CASE MANAGEMENT 11900 13119.50000 485282.7500 36.9894
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 6782 6561.750000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 7640 21209.75000 783814.0000 36.9554
Subtotal (Total Children Is Unduplicated) 17486 40891.00000 1269096.7500 31.0361
-----------------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
ASTE-ASTE-ASSISTIVE TECHNOLOGY EVAL 24 24.000000 1164.0000 48.5000
AUDE-92552-PURE TONE AUDIOMETRY -AIR ONLY 46 47.000000 926.3700 19.7100
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 50 51.000000 707.3700 13.8700
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 55 56.000000 508.4800 9.0800
AUDE-92568-ACOUSTIC REFLEX TESTING (MEMR) 1 1.000000 9.9600 9.9600
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 52 53.000000 1448.4600 27.3294
AUDE-92585-AUD EVOKED RESPONSE (COMP) 1 1.000000 84.8400 84.8400
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 20 20.000000 334.0000 16.7000
AUDE-92588-OTOACOUSTIC EMISSIONS (COMP) 9 9.000000 201.6000 22.4000
AUDE-V5010-ASSESSMENT FOR HEARING AID 1 1.000000 45.0000 45.0000
BEHV-H2014BA-BEHAVIOR ANALYSIS-ASSOCIATE 1 7.000000 341.3200 48.7600
EVAL-96111-DEVELOPMENTAL EVALUATION 82 98.250000 4912.5000 50.0000
EXIT-EXIT-EXIT ASSESSMENT 871 1423.000000 70997.5000 49.8928
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 26 38.000000 2850.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 15 23.300000 1747.5000 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 14 20.500000 1537.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 43 58.500000 3246.7500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 363 603.196932 44883.0700 74.4087
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 133 207.041467 15528.1100 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 91 147.085200 11031.3900 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 494 734.000000 40709.2500 55.4622
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 267 444.500000 33337.5000 75.0000
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 44 44.000000 2592.0400 58.9100
MED-99204-OUTPATIENT VISIT, NEW, 45 MINS 3 3.000000 249.8700 83.2900
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 5 5.000000 117.1000 23.4200
NUTR-97802-NUTRITIONAL EVAL, INITIAL 2 15.000000 750.0000 50.0000
NUTR-97803-NUTRITIONAL EVAL, FOLLOW-UP 7 30.000000 1500.0000 50.0000
OCTF-97168-OT RE-EVAL EST PLAN CARE 10 10.000000 510.5000 51.0500
OCTH-97165-OT EVAL LOW COMPLEXITY 7 7.000000 357.3500 51.0500
OCTH-97166-OT EVAL MODERATE COMPLEXITY 15 15.000000 765.7500 51.0500
OCTH-97167-OT EVAL HIGH COMPLEXITY 44 44.000000 2246.2000 51.0500
PSTF-97164-PT RE-EVAL EST PLAN CARE 5 5.000000 255.2500 51.0500
PSTH-97161-PT EVAL LOW COMPLEXITY 2 2.000000 102.1000 51.0500
PSTH-97162-PT EVAL MODERATE COMPLEXITY 7 7.000000 357.3500 51.0500
PSTH-97163-PT EVAL HIGH COMPLEXITY 28 27.167500 1304.5100 48.0173
SCREEN-T1023-SCREENING 22 23.000000 1150.0000 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 74 71.510284 3650.5800 51.0497
SPCH-92524-BEHAV & QUAL ANALYSIS OF VOICE AND RES 9 8.020568 409.4500 51.0500
Subtotal (Total Children Is Unduplicated) 2135 4394.571951 253586.1700 57.7044
-----------------------------------------------------------------------------------------------------------------------
EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 36 52.000000 23135.2200 444.9081
AUD-92592TS-AUDIOLOGY SERVICES (Monaural) 1 1.000000 50.0000 50.0000
AUD-92593TS-AUDIOLOGY SERVICES (Biaural) 2 2.000000 85.4900 42.7450
AUDE-V5160-DISPENSING FEE BINAURAL 2 3.000000 287.0300 95.6767
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 1318 1643.500000 81612.5000 49.6577
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 94 82.750000 2068.7500 25.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 1949 3276.750000 163762.5000 49.9771
CONIP-CONIP-CONSULT, ITDS PHONE 227 204.250000 5100.2500 24.9706
CONOF-CONOF-CONSULT, OT, FACE TO FACE 652 954.500000 47700.0000 49.9738
CONOP-CONOP-CONSULT, OT, PHONE 83 75.750000 1893.7500 25.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 537 703.500000 35137.5000 49.9467
CONPP-CONPP-CONSULT, PT, PHONE 14 12.000000 300.0000 25.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 1282 1679.250000 83725.0000 49.8586
CONSP-CONSP-CONSULT, SLP, PHONE 134 115.500000 2887.5000 25.0000
COUN-H2019HR-INDIVIDUAL/FAMILY THERAPY 14 33.000000 2419.5600 73.3200
DSTT-DSTT-DIRECT SERVICE COORDINATOR TRAVEL 2106 4801.000000 0.0000 0.0000
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 29 85.000000 2125.0000 25.0000
EIIF-96154-HEALTH AND BEHAVIOR INTERVENTION 1 55.000000 2750.0000 50.0000
EIIF-EIIF_NM-EI INDIVIDUAL SESSION BY NONMED PROF 10 35.000000 1750.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 2710 17457.60000 861030.6700 49.3213
INTR-T1013-INTERPRETER 288 1582.250000 68876.9000 43.5310
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 13314 112532.0000 1121714.5900 9.9680
OCCT-97530-OT SESSION BY LICENSED OT 439 2153.407606 153062.7400 71.0793
OCCT-97530HM-OT SESSION BY OT ASST 120 672.817385 38444.2200 57.1392
PHY-97110-PT SESSION BY LICENSED PT 469 2523.542700 178984.3700 70.9258
PHY-97110HM-PT SESSION BY PT ASST 35 146.057236 8348.6300 57.1600
SENS-V5140-BEHIND EAR BINAURAL HEARING AID 1 1.000000 456.0000 456.0000
SENS-V5264-EARMOLD 2 3.000000 54.0000 18.0000
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 1047 5898.221039 412417.8890 69.9224
CMS/EIP Fiscal Report Statewide
Services beginning 10/01/2018 ending 12/31/2018 Date of Report:02/06/2019 Page: 2
List order: No List
Payclass Filters:GR
Eligibility Filter:Part C (excluding not eligible)
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 1 4.000000 228.8000 57.2000
SPL-92508-GROUP SPL SESSION PER CHILD 1 1.000000 13.8800 13.8800
TRAV-TRAVS-Travel by mile 5981 514123.0000 227112.7700 0.4417
Subtotal (Total Children Is Unduplicated) 16425 670912.6460 3527535.5090 5.2578
-----------------------------------------------------------------------------------------------------------------------
Total 716198.217917 5050218.4290 7.0514
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 23231
-----------------------------------------------------------------------------------------------------------------------
Center 01
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 1 0.250000 9.2500 0.0000
P 18898 87093.500000 264009.7200 264083.7200
D 341 1358.250000 4762.1500 0.0000
S 110 405.500000 2859.9200 0.0000
H 0 0.000000 0.0000 0.0000
T 1167 4825.750000 15896.4300 15898.2100
4100 2763.500000 71707.4100 0.0000
Other 6 3.000000 214.3200 0.0000
---------------------------------------------------------
Total 24623 96449.750000 359459.2000 279981.9300
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 4 4.000000 40.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 5220 14757.250000 114872.7100 113671.0100
328 1028.500000 5531.5500 0.0000
Other 3019 15519.250000 52596.8200 0.0000
---------------------------------------------------------
Total 8571 31309.000000 173041.0800 113671.0100
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 5447 54992.000000 140169.2800 140169.2800
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
8952 39940.000000 211187.7600 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 14399 94932.000000 351357.0400 140169.2800
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 3792 15055.750000 259544.6600 259544.6600
D 28 37.500000 1387.5000 0.0000
S 0 0.000000 0.0000 0.0000
H 30 117.500000 4843.6900 834.6400
T 0 0.000000 0.0000 0.0000
3895 3604.000000 141667.5200 0.0000
Other 3 9.500000 347.1600 347.1600
---------------------------------------------------------
Total 7748 18824.250000 407790.5300 260726.4600
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 1760 20650.000000 51590.8500 51590.8500
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
2430 1417.750000 41615.7500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 4190 22067.750000 93206.6000 51590.8500
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 8428 8283.500000 115156.2300 115156.2300
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
12378 8904.000000 189803.3300 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 20806 17187.500000 304959.5600 115156.2300
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 2700 9213.500000 181802.5000 181802.5000
D 179 143.250000 5982.2500 0.0000
S 1 60.000000 2220.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
6507 4181.000000 128038.2500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 9387 13597.750000 318043.0000 181802.5000
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 15872 117997.250000 630430.0800 630430.0800
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
644 14530.750000 37165.7300 0.0000
Other 1 1.500000 83.2500 0.0000
---------------------------------------------------------
Total 16517 132529.500000 667679.0600 630430.0800
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 10494 31334.500000 780330.8800 780330.8800
D 61 46.750000 1637.7800 0.0000
S 124 236.250000 5992.9100 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
3968 3280.250000 111191.5000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 14647 34897.750000 899153.0700 780330.8800
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 1638 9709.500000 89188.6600 89188.6600
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
1878 1384.250000 49548.2500 50.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 3516 11093.750000 138736.9100 89238.6600
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 3 55.250000 78.5000 78.5000
D 2 4.000000 222.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 5938 54511.250000 164083.1200 160536.4000
2932 1646.750000 43510.5400 197.2900
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 8875 56217.250000 207894.1600 160812.1900
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 1 1.000000 73.3200 0.0000
S 0 0.000000 0.0000 0.0000
H 2186 15591.250000 24784.2500 24784.2500
T 3396 28755.500000 38073.8100 38073.8100
11756 13003.000000 147742.0500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 17339 57350.750000 210673.4300 62858.0600
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 211 181.750000 8091.0700 0.0000
S 0 0.000000 0.0000 0.0000
H 4881 28043.610000 59079.6300 59079.6300
T 2341 14434.750000 28485.8700 28485.8700
15571 33445.720000 183219.6500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 23004 76105.830000 278876.2200 87565.5000
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 8423 16515.883809 176257.4899 176257.4900
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
8050 8930.004108 167421.0491 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 16473 25445.887917 343678.5390 176257.4900
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 0 0.000000 0.0000 0.0000
S 39 68.000000 2012.5700 2012.5700
H 0 0.000000 0.0000 0.0000
T 3569 24889.000000 170579.0600 170577.3400
3196 3227.500000 122988.4000 5580.1000
Other 2 5.000000 90.0000 90.0000
---------------------------------------------------------
Total 6806 28189.500000 295670.0300 178260.0100