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: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 12684 13935.00000 515456.2500 36.9900
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 7434 7222.500000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 8194 23272.50000 859849.0000 36.9470
Subtotal (Total Children Is Unduplicated) 18721 44430.00000 1375305.2500 30.9544
-----------------------------------------------------------------------------------------------------------------------
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 87 114.250000 5712.5000 50.0000
EXIT-EXIT-EXIT ASSESSMENT 873 1426.000000 71147.5000 49.8931
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 33 50.000000 3750.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 21 32.300000 2422.5000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 6 9.000000 675.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 17 26.000000 1950.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 52 73.500000 4079.2500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 451 745.030265 55483.0700 74.4709
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 180 278.067067 20816.0300 74.8597
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 115 185.585200 13918.8900 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 632 935.500000 51809.2500 55.3813
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 320 524.500000 39337.5000 75.0000
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 53 53.000000 3122.2300 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) 2370 4998.430884 293874.2800 58.7933
-----------------------------------------------------------------------------------------------------------------------
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 1319 1644.500000 81662.5000 49.6580
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 94 82.750000 2068.7500 25.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 1952 3280.500000 163950.0000 49.9771
CONIP-CONIP-CONSULT, ITDS PHONE 227 204.250000 5100.2500 24.9706
CONOF-CONOF-CONSULT, OT, FACE TO FACE 653 954.750000 47712.5000 49.9738
CONOP-CONOP-CONSULT, OT, PHONE 83 75.750000 1893.7500 25.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 538 704.250000 35175.0000 49.9468
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 2298 5008.000000 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 2711 17460.60000 861180.6700 49.3214
INTR-T1013-INTERPRETER 313 1638.500000 71489.4000 43.6310
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 13533 112957.0000 1125964.5900 9.9681
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:Program Patients
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 6180 520652.0000 230009.7500 0.4418
Subtotal (Total Children Is Unduplicated) 16792 678138.6460 3537732.4890 5.2168
-----------------------------------------------------------------------------------------------------------------------
Total 727567.076850 5206912.0190 7.1566
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 24527
-----------------------------------------------------------------------------------------------------------------------
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 18943 87647.750000 265967.4100 266041.4100
D 346 1367.750000 4869.2900 0.0000
S 113 443.500000 2875.5600 0.0000
H 0 0.000000 0.0000 0.0000
T 1169 4829.500000 16092.1800 16081.4600
4348 2952.500000 77268.1600 0.0000
Other 6 3.000000 214.3200 0.0000
---------------------------------------------------------
Total 24926 97244.250000 367296.1700 282122.8700
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 5252 15425.750000 116628.2800 115426.5800
328 1028.500000 5531.5500 0.0000
Other 3231 17123.750000 56378.0500 0.0000
---------------------------------------------------------
Total 8815 33582.000000 178577.8800 115426.5800
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 5452 55001.000000 140524.2800 140524.2800
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
9397 40342.500000 227826.0100 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 14849 95343.500000 368350.2900 140524.2800
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 29 42.500000 1572.5000 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
4191 3930.750000 155063.4600 0.0000
Other 3 9.500000 347.1600 347.1600
---------------------------------------------------------
Total 8045 19156.000000 421371.4700 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 1787 20879.000000 52984.0100 52984.0100
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
2648 1561.500000 45556.2500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 4435 22440.500000 98540.2600 52984.0100
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 8432 8287.500000 115196.2300 115196.2300
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
12714 9156.000000 198113.0800 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 21146 17443.500000 313309.3100 115196.2300
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 2716 9230.000000 182035.7500 182035.7500
D 180 145.750000 6074.7500 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
6868 4481.500000 137874.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 9765 13917.250000 328204.5000 182035.7500
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 16242 118542.250000 646458.9200 646458.9200
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
647 14533.750000 37276.7300 0.0000
Other 2 3.000000 166.5000 0.0000
---------------------------------------------------------
Total 16891 133079.000000 683902.1500 646458.9200
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
4166 3498.000000 119639.2500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 14845 35115.500000 907600.8200 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 1667 9769.500000 89912.5100 89912.5100
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
2018 1508.750000 53825.7500 50.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 3685 11278.250000 143738.2600 89962.5100
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 6008 55579.250000 164966.8600 161379.1400
3189 1846.250000 50152.0400 197.2900
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 9202 57484.750000 215419.4000 161654.9300
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 2202 15702.500000 24922.6000 24922.6000
T 3431 29029.000000 38586.5300 38586.5300
12375 13607.750000 156657.8300 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 18009 58340.250000 220240.2800 63509.1300
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 215 190.000000 8453.3200 0.0000
S 0 0.000000 0.0000 0.0000
H 4968 28762.860000 60152.5100 60152.5100
T 2382 14858.750000 28975.8000 28975.8000
16392 34824.470000 196605.8300 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 23957 78636.080000 294187.4600 89128.3100
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 8440 16548.909409 178311.4099 178311.4100
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
8595 9342.837441 182341.5491 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 17035 25891.746850 360652.9590 178311.4100
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 3575 25043.000000 170733.5900 170731.8700
3390 3498.500000 132684.6500 5580.1000
Other 2 5.000000 90.0000 90.0000
---------------------------------------------------------
Total 7006 28614.500000 305520.8100 178414.5400