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:TPIN
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 2 1.000000 37.0000 37.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 1 0.250000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 26 42.250000 1563.2500 37.0000
Subtotal (Total Children Is Unduplicated) 27 43.500000 1600.2500 36.7874
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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 11 11.000000 216.8100 19.7100
AUDE-92553-PURE TONE AUDIOMETRY AIR & BONE 1 1.000000 23.4900 23.4900
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 16 18.000000 235.7900 13.0994
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 17 18.000000 154.3600 8.5756
AUDE-92568-ACOUSTIC REFLEX TESTING (MEMR) 1 1.000000 9.9600 9.9600
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 16 17.000000 473.1100 27.8300
AUDE-92586-AUD EVOKED RESPONSE (LIMITED) 1 2.000000 59.0600 29.5300
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 5 5.000000 83.5000 16.7000
AUDE-92588-OTOACOUSTIC EMISSIONS (COMP) 4 4.000000 89.6000 22.4000
AUDE-V5010-ASSESSMENT FOR HEARING AID 1 1.000000 45.0000 45.0000
AUDE-V5090-DISPENSING FEE PER HEARING AID 1 1.000000 115.0000 115.0000
BEHV-H2014BA-BEHAVIOR ANALYSIS-ASSOCIATE 2 12.000000 576.8800 48.0733
EVAL-96111-DEVELOPMENTAL EVALUATION 3 7.500000 375.0000 50.0000
EXIT-EXIT-EXIT ASSESSMENT 2 2.000000 100.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 26 44.000000 3111.4600 70.7150
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 18 31.700000 2377.5000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 5 11.000000 825.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 18 34.000000 2756.4400 81.0718
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 32 63.000000 3474.3000 55.1476
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 574 1007.803068 72673.3400 72.1107
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 219 391.958533 28934.8400 73.8212
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 105 193.914800 14262.0900 73.5482
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 627 1117.500000 60478.2200 54.1192
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 277 493.000000 37495.4600 76.0557
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 13 13.000000 3637.3600 279.7969
MED-99204-OUTPATIENT VISIT, NEW, 45 MINS 3 3.000000 1253.9300 417.9767
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 2 2.000000 111.9700 55.9850
OCTF-97168-OT RE-EVAL EST PLAN CARE 8 8.000000 408.4000 51.0500
OCTH-97165-OT EVAL LOW COMPLEXITY 9 9.000000 399.4200 44.3800
OCTH-97166-OT EVAL MODERATE COMPLEXITY 18 17.000000 867.8500 51.0500
OCTH-97167-OT EVAL HIGH COMPLEXITY 23 23.000000 1124.1500 48.8761
PSTF-97164-PT RE-EVAL EST PLAN CARE 4 4.000000 131.9400 32.9850
PSTH-97161-PT EVAL LOW COMPLEXITY 2 3.000000 109.2500 36.4167
PSTH-97162-PT EVAL MODERATE COMPLEXITY 2 2.000000 102.1000 51.0500
PSTH-97163-PT EVAL HIGH COMPLEXITY 23 22.832500 1145.6000 50.1741
SCREEN-T1023-SCREENING 14 14.000000 700.0000 50.0000
SPCH-92521-EVAL OF SPEECH FLUENCY 2 2.000000 102.1000 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 60 59.469148 2925.9000 49.2003
SPCH-92524-BEHAV & QUAL ANALYSIS OF VOICE AND RES 11 11.000000 516.5500 46.9591
SPCH-92610-EVAL OF ORAL,PHARYNGEAL SWALLOWING FUNC 5 5.000000 244.7000 48.9400
Subtotal (Total Children Is Unduplicated) 1188 3690.678049 242926.5300 65.8217
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 8 44.000000 3041.1000 69.1159
AUD-92593TS-AUDIOLOGY SERVICES (Biaural) 2 2.000000 100.0000 50.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 2 2.000000 100.0000 50.0000
CONIP-CONIP-CONSULT, ITDS PHONE 2 2.000000 50.0000 25.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 1 1.000000 50.0000 50.0000
CONSP-CONSP-CONSULT, SLP, PHONE 2 1.500000 37.5000 25.0000
COUN-H2019HR-INDIVIDUAL/FAMILY THERAPY 2 6.000000 439.9200 73.3200
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 2 2.000000 50.0000 25.0000
EIIF-96154-HEALTH AND BEHAVIOR INTERVENTION 2 20.000000 1000.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 1371 9127.150000 455783.9000 49.9372
INTR-T1013-INTERPRETER 6 12.500000 625.0000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 2 2.000000 20.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 443 2211.092386 148769.0892 67.2831
OCCT-97530HM-OT SESSION BY OT ASST 140 784.740304 44635.0000 56.8787
PHY-97110-PT SESSION BY LICENSED PT 409 2266.925400 149848.8500 66.1022
PHY-97110HM-PT SESSION BY PT ASST 30 198.944564 11364.4200 57.1236
SENS-V5014-*HEARING AID REPAIR BY MANUFACTURER 1 1.000000 114.0000 114.0000
SENS-V5264-EARMOLD 3 6.000000 108.0000 18.0000
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 966 5518.002463 370475.4603 67.1394
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 3 17.000000 972.4000 57.2000
SPL-92508-GROUP SPL SESSION PER CHILD 4 9.699900 174.9200 18.0332
TRAV-TRAVS-Travel by mile 2 6.000000 2.6800 0.4467
Subtotal (Total Children Is Unduplicated) 2825 20241.55502 1187762.2395 58.6794
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Total 23975.733066 1432289.0195 59.7391
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Number of Children (Unduplicated) With at Least One Service 3525
-----------------------------------------------------------------------------------------------------------------------
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 2718 2788.000000 149183.5900 149183.5900
D 70 69.250000 3256.6800 0.0000
S 71 76.000000 4072.4000 0.0000
H 150 191.500000 13866.4100 0.0000
T 235 235.000000 12628.6500 12567.2100
135 154.500000 8713.4200 0.0000
Other 34 45.000000 2790.2000 450.0000
---------------------------------------------------------
Total 3413 3559.250000 194511.3500 162200.8000
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 452 393.000000 25939.8600 25302.7300
13 8.000000 510.3500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 465 401.000000 26450.2100 25302.7300
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 158 156.500000 9325.8900 9325.8900
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
133 131.250000 7841.4400 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 291 287.750000 17167.3300 9325.8900
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 131 253.000000 17586.5100 14223.6200
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
113 106.750000 10466.9200 0.0000
Other 75 202.500000 13714.3100 0.0000
---------------------------------------------------------
Total 319 562.250000 41767.7400 14223.6200
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 47 88.000000 5968.0600 5968.0600
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 47 88.000000 5968.0600 5968.0600
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 2588 2173.750000 119661.7800 119661.7800
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
2611 2174.500000 128950.5700 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 5199 4348.250000 248612.3500 119661.7800
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 116 356.000000 23722.8600 23472.8600
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 116 356.000000 23722.8600 23472.8600
Center 09
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 1 1.500000 112.5000 0.0000
P 375 683.000000 38642.5600 38764.3700
D 11 11.000000 785.8400 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
441 923.000000 63897.3900 0.0000
Other 22 38.500000 2887.5000 0.0000
---------------------------------------------------------
Total 850 1657.000000 106325.7900 38764.3700
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 332 574.500000 33754.4800 33754.4800
D 1 0.500000 35.7200 0.0000
S 4 7.000000 462.6600 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
998 2046.000000 138104.5700 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 1335 2628.000000 172357.4300 33754.4800
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 447 1364.000000 92793.7600 92793.7600
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
10 24.000000 1714.5600 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 457 1388.000000 94508.3200 92793.7600
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 69 67.750000 4673.8700 3286.0300
D 31 46.250000 2528.9100 60.0000
S 0 0.000000 0.0000 0.0000
H 115 189.750000 12816.3600 0.0000
T 755 1165.750000 69375.2100 62563.1200
426 643.750000 36842.9100 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 1396 2113.250000 126237.2600 65909.1500
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 44 33.820600 1689.5300 1833.6700
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 68 64.037512 3493.8600 3493.8600
T 44 47.000000 2578.9600 2578.9600
656 695.391880 36186.5692 0.0000
Other 199 226.500000 12625.9700 0.0000
---------------------------------------------------------
Total 1011 1066.749992 56574.8892 7906.4900
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 8 4.650000 234.4000 255.4000
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 103 105.500000 5657.7200 5657.7200
T 46 48.500000 2606.9500 2606.9500
661 687.270000 37394.2800 0.0000
Other 27 28.250000 1462.5000 0.0000
---------------------------------------------------------
Total 845 874.170000 47355.8500 8520.0700
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 879 834.750000 55442.5200 55442.5200
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 19 38.000000 2850.0000 0.0000
T 0 0.000000 0.0000 0.0000
952 854.313074 57048.3003 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 1850 1727.063074 115340.8203 55442.5200
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 23 13.000000 908.3300 908.3300
D 0 0.000000 0.0000 0.0000
S 2 11.000000 550.0000 550.0000
H 0 0.000000 0.0000 0.0000
T 699 2336.000000 117621.8200 117621.8200
383 559.000000 36308.6100 19741.0200
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 1107 2919.000000 155388.7600 138821.1700