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: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 3 1.250000 46.2500 37.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 1 0.250000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 29 45.750000 1692.7500 37.0000
Subtotal (Total Children Is Unduplicated) 31 47.250000 1739.0000 36.8042
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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 29 48.000000 3326.1300 69.2944
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 20 36.500000 2943.9400 80.6559
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 37 72.500000 4001.5500 55.1938
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 730 1256.969735 90399.3400 71.9185
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 280 493.932933 36487.9200 73.8722
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 139 250.914800 18332.7500 73.0636
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 810 1414.000000 76814.8700 54.3245
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 355 600.000000 46063.0100 76.7717
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 16 16.000000 4142.2600 258.8913
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) 1461 4521.319116 298614.7900 66.0459
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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 1375 9140.150000 456433.9000 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 967 5522.002463 370761.2203 67.1425
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) 2830 20258.55502 1188697.9995 58.6763
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Total 24827.124133 1489051.7895 59.9768
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Number of Children (Unduplicated) With at Least One Service 3805
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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 2744 2829.000000 151672.2600 151672.2600
D 70 69.250000 3256.6800 0.0000
S 71 76.000000 4072.4000 0.0000
H 156 199.500000 14466.4100 0.0000
T 238 241.000000 12946.8000 12885.3600
143 165.500000 9392.1700 0.0000
Other 38 50.500000 3134.4500 450.0000
---------------------------------------------------------
Total 3460 3630.750000 198941.1700 165007.6200
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 455 398.500000 26352.3600 25565.2300
13 8.000000 510.3500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 468 406.500000 26862.7100 25565.2300
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 138 260.000000 18875.6800 15512.7900
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
175 163.750000 14564.8300 0.0000
Other 75 202.500000 13714.3100 0.0000
---------------------------------------------------------
Total 388 626.250000 47154.8200 15512.7900
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 2590 2176.750000 119857.5300 119857.5300
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
2667 2254.500000 134287.5700 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 5257 4431.250000 254145.1000 119857.5300
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 398 717.500000 40642.7300 40764.5400
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
481 987.000000 68114.0100 0.0000
Other 30 49.500000 3712.5000 0.0000
---------------------------------------------------------
Total 921 1766.500000 113367.5800 40764.5400
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
1057 2156.500000 145465.8200 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 1394 2738.500000 179718.6800 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 450 1368.000000 93079.5200 93079.5200
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 460 1392.000000 94794.0800 93079.5200
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 75 79.750000 5456.8700 3661.3100
D 32 48.250000 2639.9100 60.0000
S 0 0.000000 0.0000 0.0000
H 138 233.250000 15679.1100 0.0000
T 785 1224.750000 73068.0300 66215.9400
452 689.250000 39668.8300 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 1482 2275.250000 136512.7500 69937.2500
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
664 707.391880 36939.0692 0.0000
Other 222 262.500000 14963.9700 0.0000
---------------------------------------------------------
Total 1042 1114.749992 59665.3892 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 104 106.500000 5732.7200 5732.7200
T 47 50.000000 2690.2000 2690.2000
700 746.520000 41190.0300 0.0000
Other 27 28.250000 1462.5000 0.0000
---------------------------------------------------------
Total 886 935.920000 51309.8500 8678.3200
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 886 848.750000 56492.5200 56492.5200
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 28 56.000000 4200.0000 0.0000
T 0 0.000000 0.0000 0.0000
967 879.954141 58971.3803 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 1881 1784.704141 119663.9003 56492.5200
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 704 2347.000000 118257.8200 118257.8200
447 622.000000 40341.3600 19741.0200
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 1176 2993.000000 160057.5100 139457.1700