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
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 12686 13936.25000 515502.5000 36.9900
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 7566 7317.250000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 23033 66981.00000 2475528.5000 36.9587
Subtotal (Total Children Is Unduplicated) 24392 88234.50000 2991031.0000 33.8987
-----------------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
ASTE-ASTE-ASSISTIVE TECHNOLOGY EVAL 26 26.000000 1261.0000 48.5000
AUDE-92552-PURE TONE AUDIOMETRY -AIR ONLY 57 58.000000 1143.1800 19.7100
AUDE-92553-PURE TONE AUDIOMETRY AIR & BONE 1 1.000000 23.4900 23.4900
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 66 69.000000 943.1600 13.6690
AUDE-92557-COMP AUDIO THRESHOLD EVAL/SPCH RECOG 1 3.000000 51.5500 17.1833
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 72 74.000000 662.8400 8.9573
AUDE-92568-ACOUSTIC REFLEX TESTING (MEMR) 2 2.000000 19.9200 9.9600
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 68 70.000000 1921.5700 27.4510
AUDE-92585-AUD EVOKED RESPONSE (COMP) 1 1.000000 84.8400 84.8400
AUDE-92586-AUD EVOKED RESPONSE (LIMITED) 1 2.000000 59.0600 29.5300
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 25 25.000000 417.5000 16.7000
AUDE-92588-OTOACOUSTIC EMISSIONS (COMP) 13 13.000000 291.2000 22.4000
AUDE-V5010-ASSESSMENT FOR HEARING AID 2 2.000000 90.0000 45.0000
AUDE-V5090-DISPENSING FEE PER HEARING AID 1 1.000000 115.0000 115.0000
BEHV-H2014BA-BEHAVIOR ANALYSIS-ASSOCIATE 3 19.000000 918.2000 48.3263
EVAL-96111-DEVELOPMENTAL EVALUATION 90 121.750000 6087.5000 50.0000
EXIT-EXIT-EXIT ASSESSMENT 887 1450.000000 72347.5000 49.8948
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 195 327.500000 24288.6300 74.1638
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 103 169.000000 12675.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 30 53.500000 4012.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 93 159.000000 12131.4400 76.2984
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 226 390.500000 21650.5500 55.4431
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 2934 4841.500000 358844.9100 74.1185
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 1326 2150.000000 160653.9500 74.7228
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 624 1066.000000 79464.1400 74.5442
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 3682 6022.000000 332331.3700 55.1862
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 1611 2641.000000 199100.5100 75.3883
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 90 90.000000 8501.6000 94.4622
MED-99204-OUTPATIENT VISIT, NEW, 45 MINS 12 12.000000 2003.5400 166.9617
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 16 16.000000 439.8500 27.4906
MED-99214-OUTPATIENT VISIT, EST, 25 MINS 1 1.000000 36.4900 36.4900
NUTR-97802-NUTRITIONAL EVAL, INITIAL 2 19.000000 950.0000 50.0000
NUTR-97803-NUTRITIONAL EVAL, FOLLOW-UP 7 45.000000 2250.0000 50.0000
OCTF-97168-OT RE-EVAL EST PLAN CARE 31 31.000000 1582.5500 51.0500
OCTH-97165-OT EVAL LOW COMPLEXITY 16 16.000000 756.7700 47.2981
OCTH-97166-OT EVAL MODERATE COMPLEXITY 48 47.000000 2399.3500 51.0500
OCTH-97167-OT EVAL HIGH COMPLEXITY 103 104.000000 5259.2000 50.5692
PSTF-97164-PT RE-EVAL EST PLAN CARE 14 14.000000 642.4400 45.8886
PSTH-97161-PT EVAL LOW COMPLEXITY 4 5.000000 211.3500 42.2700
PSTH-97162-PT EVAL MODERATE COMPLEXITY 15 15.000000 765.7500 51.0500
PSTH-97163-PT EVAL HIGH COMPLEXITY 91 91.000000 4543.1600 49.9248
SCREEN-T1023-SCREENING 81 87.000000 4350.0000 50.0000
SPCH-92521-EVAL OF SPEECH FLUENCY 3 3.000000 153.1500 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 170 169.979432 8567.4300 50.4027
SPCH-92524-BEHAV & QUAL ANALYSIS OF VOICE AND RES 27 26.020568 1283.3500 49.3206
SPCH-92610-EVAL OF ORAL,PHARYNGEAL SWALLOWING FUNC 5 5.000000 244.7000 48.9400
Subtotal (Total Children Is Unduplicated) 6906 20559.75000 1336786.4400 65.0196
-----------------------------------------------------------------------------------------------------------------------
EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 44 96.000000 26176.3200 272.6700
AUD-92592TS-AUDIOLOGY SERVICES (Monaural) 1 1.000000 50.0000 50.0000
AUD-92593TS-AUDIOLOGY SERVICES (Biaural) 4 4.000000 185.4900 46.3725
AUDE-V5160-DISPENSING FEE BINAURAL 2 3.000000 287.0300 95.6767
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 1346 1689.250000 83900.0000 49.6670
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 107 95.250000 2381.2500 25.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 1956 3291.500000 164500.0000 49.9772
CONIP-CONIP-CONSULT, ITDS PHONE 229 206.250000 5150.2500 24.9709
CONOF-CONOF-CONSULT, OT, FACE TO FACE 661 963.250000 48137.5000 49.9740
CONOP-CONOP-CONSULT, OT, PHONE 83 75.750000 1893.7500 25.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 541 713.750000 35650.0000 49.9475
CONPP-CONPP-CONSULT, PT, PHONE 14 12.000000 300.0000 25.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 1294 1692.250000 84375.0000 49.8597
CONSP-CONSP-CONSULT, SLP, PHONE 136 117.000000 2925.0000 25.0000
COUN-H2019HR-INDIVIDUAL/FAMILY THERAPY 16 39.000000 2859.4800 73.3200
DSTT-DSTT-DIRECT SERVICE COORDINATOR TRAVEL 2298 5008.000000 0.0000 0.0000
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 125 5893.750000 147343.7500 25.0000
EIIF-96154-HEALTH AND BEHAVIOR INTERVENTION 3 75.000000 3750.0000 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 10574 78637.25000 3915814.7700 49.7959
INTR-T1013-INTERPRETER 317 1651.000000 72114.4000 43.6792
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 13538 113018.0000 1126574.5900 9.9681
OCCT-97530-OT SESSION BY LICENSED OT 1253 6675.749992 466947.5292 69.9468
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
Eligibility Filter:Program Patients
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
OCCT-97530HM-OT SESSION BY OT ASST 436 2606.550699 148773.0200 57.0766
PHY-97110-PT SESSION BY LICENSED PT 1233 7313.718100 509037.6400 69.6004
PHY-97110HM-PT SESSION BY PT ASST 187 1031.751800 58967.6800 57.1530
SENS-V5014-*HEARING AID REPAIR BY MANUFACTURER 1 1.000000 114.0000 114.0000
SENS-V5140-BEHIND EAR BINAURAL HEARING AID 1 1.000000 456.0000 456.0000
SENS-V5264-EARMOLD 5 9.000000 162.0000 18.0000
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 2606 16433.97350 1140697.4893 69.4109
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 5 36.000000 2059.2000 57.2000
SPL-92508-GROUP SPL SESSION PER CHILD 12 27.699900 424.7600 15.3344
TRAV-TRAVS-Travel by mile 6304 564921.0000 249504.3100 0.4417
Subtotal (Total Children Is Unduplicated) 17466 812374.6940 8303262.2085 10.2210
-----------------------------------------------------------------------------------------------------------------------
Total 921168.943993 12631079.6485 13.7120
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 27374
-----------------------------------------------------------------------------------------------------------------------
Center 01
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 616 441.250000 18223.0900 0.0000
U 0 0.000000 0.0000 0.0000
B 745 823.250000 50257.8700 0.0000
P 28059 94608.250000 572189.5000 569353.9500
D 536 1556.000000 14011.8000 0.0000
S 195 534.000000 7809.0900 0.0000
H 158 200.500000 14503.4100 37.0000
T 1408 5071.250000 29066.7300 28966.8200
4500 3120.750000 86762.0800 0.0000
Other 450 594.500000 35928.4700 450.0000
---------------------------------------------------------
Total 36667 106949.750000 828752.0400 598807.7700
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 5707 15824.250000 142980.6400 140991.8100
341 1036.500000 6041.9000 0.0000
Other 4886 18356.750000 111979.3000 0.0000
---------------------------------------------------------
Total 10938 35221.500000 261041.8400 140991.8100
Center 03
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 97 72.500000 3254.2500 0.0000
U 0 0.000000 0.0000 0.0000
B 3072 2366.250000 104534.7500 0.0000
P 5610 55157.500000 149850.1700 149850.1700
D 0 0.000000 0.0000 0.0000
S 2 1.750000 64.7500 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
9564 40532.250000 239708.2000 0.0000
Other 1 0.500000 18.5000 0.0000
---------------------------------------------------------
Total 18346 98130.750000 497430.6200 149850.1700
Center 04
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 8 8.500000 314.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 1207 1769.000000 68749.0000 0.0000
P 6745 19765.250000 454689.2200 448628.8400
D 29 42.500000 1572.5000 0.0000
S 0 0.000000 0.0000 0.0000
H 2572 10922.000000 554677.3900 834.6400
T 0 0.000000 0.0000 0.0000
5198 10673.250000 368765.8000 0.0000
Other 78 212.000000 14061.4700 347.1600
---------------------------------------------------------
Total 15837 43392.500000 1462829.8800 449810.6400
Center 05
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 65 46.250000 1711.2500 0.0000
U 0 0.000000 0.0000 0.0000
B 2272 1531.500000 60339.2500 0.0000
P 1836 20969.500000 59139.5700 59139.5700
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
2649 1562.250000 45584.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 6822 24109.500000 166774.0700 59139.5700
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 11022 10464.250000 235053.7600 235053.7600
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
27322 21755.250000 829934.6200 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 38344 32219.500000 1064988.3800 235053.7600
Center 07
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 13 9.500000 351.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 41 36.500000 1439.5000 0.0000
P 6670 12971.250000 350352.5000 350037.7500
D 180 145.750000 6074.7500 0.0000
S 9 68.000000 2620.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
6903 4505.500000 138856.5000 0.0000
Other 2 1.000000 37.0000 0.0000
---------------------------------------------------------
Total 13818 17737.500000 499731.7500 350037.7500
Center 09
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 202 241.250000 8926.2500 0.0000
U 0 0.000000 0.0000 0.0000
B 1777 1735.750000 68885.5000 124.5000
P 22460 170274.500000 1048572.5400 1048584.4900
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
3537 22956.500000 515154.4300 0.0000
Other 257 420.000000 30838.0000 0.0000
---------------------------------------------------------
Total 28244 195639.000000 1673162.5600 1048708.9900
Center 10
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 402 317.000000 11729.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 5337 4969.000000 220869.7500 0.0000
P 10826 31909.000000 814085.3600 814085.3600
D 62 47.250000 1673.5000 0.0000
S 237 441.750000 17736.0700 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
9668 19525.750000 1004404.0500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 26532 57209.750000 2070497.7300 814085.3600
Center 51
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 230 165.750000 6031.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 626 441.000000 17109.0000 0.0000
P 2118 11141.500000 183277.7900 183277.7900
D 1 0.750000 27.7500 0.0000
S 0 0.000000 0.0000 0.0000
H 1 0.250000 9.2500 0.0000
T 0 0.000000 0.0000 0.0000
2800 3534.500000 175584.0500 50.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 5776 15283.750000 382038.8400 183327.7900
Center 52
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 7 3.500000 142.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 1090 1102.500000 54661.5000 83.2500
P 2526 2442.750000 109837.6700 107098.7700
D 41 58.500000 3244.0900 150.0000
S 6 7.000000 259.0000 0.0000
H 184 277.000000 18634.1400 0.0000
T 6795 56806.000000 238135.9400 227696.1300
4425 4145.750000 189323.1200 268.7300
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 15074 64843.000000 614237.9600 335296.8800
Center 53
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 21 18.500000 739.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 837 789.000000 32932.5000 29.7500
P 2902 2956.320600 138660.0300 138767.1700
D 1 1.000000 73.3200 0.0000
S 19 19.250000 776.0000 0.0000
H 2270 15766.537512 28416.4600 28416.4600
T 3475 29076.000000 41165.4900 41165.4900
15160 16495.391880 304341.5992 0.0000
Other 224 264.500000 15063.9700 0.0000
---------------------------------------------------------
Total 24909 65386.499992 562168.8692 208378.8700
Center 54
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 3 3.000000 150.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 1801 1436.500000 57609.5000 0.0000
P 4005 3529.650000 156840.9000 175223.4000
D 215 190.000000 8453.3200 0.0000
S 0 0.000000 0.0000 0.0000
H 5072 28869.360000 65885.2300 65885.2300
T 2429 14908.750000 31666.0000 31666.0000
20463 39018.990000 411289.7900 0.0000
Other 32 32.500000 1619.7500 0.0000
---------------------------------------------------------
Total 34020 87988.750000 733514.4900 272774.6300
Center 55
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 2 0.500000 18.5000 0.0000
P 13079 20604.159409 370747.4299 370747.4300
D 0 0.000000 0.0000 0.0000
S 5 3.500000 168.5000 0.0000
H 28 56.000000 4200.0000 0.0000
T 0 0.000000 0.0000 0.0000
14339 15059.784592 531671.0994 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 27453 35723.944001 906805.5293 370747.4300
Center 57
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 1 0.500000 18.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 2298 2819.500000 106232.2500 0.0000
P 388 394.750000 24413.3300 24224.1300
D 1 1.000000 75.0000 0.0000
S 48 85.500000 2861.1700 2861.1700
H 0 0.000000 0.0000 0.0000
T 4280 27394.000000 289191.4100 289189.6900
6259 10517.000000 480338.7900 295405.9000
Other 52 121.000000 3974.6400 3974.6400
---------------------------------------------------------
Total 13327 41333.250000 907105.0900 615655.5300