CMS/EIP Fiscal Report Statewide
Services beginning 01/01/2019 ending 03/31/2019 Date of Report:05/04/2019 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 1 2.750000 101.7500 37.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 2 3.500000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 48 85.000000 3145.0000 37.0000
Subtotal (Total Children Is Unduplicated) 49 91.250000 3246.7500 35.5808
-----------------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
ASTE-ASTE-ASSISTIVE TECHNOLOGY EVAL 1 1.000000 48.5000 48.5000
AUDE-92552-PURE TONE AUDIOMETRY -AIR ONLY 17 18.000000 354.7800 19.7100
AUDE-92553-PURE TONE AUDIOMETRY AIR & BONE 3 4.000000 93.9600 23.4900
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 26 30.000000 409.2000 13.6400
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 28 33.000000 290.5600 8.8048
AUDE-92568-ACOUSTIC REFLEX TESTING (MEMR) 1 1.000000 9.9600 9.9600
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 29 32.000000 862.7300 26.9603
AUDE-92585-AUD EVOKED RESPONSE (COMP) 1 1.000000 84.8400 84.8400
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 11 11.000000 183.7000 16.7000
AUDE-92588-OTOACOUSTIC EMISSIONS (COMP) 6 6.000000 134.4000 22.4000
AUDE-V5010-ASSESSMENT FOR HEARING AID 2 2.000000 90.0000 45.0000
AUDE-V5090-DISPENSING FEE PER HEARING AID 2 4.000000 460.0000 115.0000
BEHV-H2014BA-BEHAVIOR ANALYSIS-ASSOCIATE 5 21.000000 1023.9600 48.7600
EVAL-96111-DEVELOPMENTAL EVALUATION 5 12.500000 625.0000 50.0000
EXIT-EXIT-EXIT ASSESSMENT 2 2.000000 100.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 34 55.500000 3984.3500 71.7901
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 13 24.500000 1737.5000 70.9184
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 5 9.000000 675.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 25 41.500000 3521.3200 84.8511
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 33 59.500000 3155.2500 53.0294
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 603 1038.166667 76281.8700 73.4775
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 172 316.111196 23256.8800 73.5718
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 108 194.269466 14163.2000 72.9049
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 672 1172.499999 64256.7500 54.8032
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 273 469.166667 36066.5000 76.8735
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 23 23.000000 5663.2100 246.2265
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 7 7.000000 1351.0000 193.0000
OCTF-97168-OT RE-EVAL EST PLAN CARE 8 7.195900 342.0100 47.5285
OCTH-97165-OT EVAL LOW COMPLEXITY 6 6.000000 306.3000 51.0500
OCTH-97166-OT EVAL MODERATE COMPLEXITY 12 13.000000 612.6000 47.1231
OCTH-97167-OT EVAL HIGH COMPLEXITY 26 26.000000 1309.1300 50.3512
PSTF-97164-PT RE-EVAL EST PLAN CARE 7 6.999999 301.6700 43.0957
PSTH-97161-PT EVAL LOW COMPLEXITY 1 1.000000 51.0500 51.0500
PSTH-97162-PT EVAL MODERATE COMPLEXITY 5 5.000000 200.3400 40.0680
PSTH-97163-PT EVAL HIGH COMPLEXITY 13 13.000000 663.6500 51.0500
SCREEN-T1023-SCREENING 18 18.000000 900.0000 50.0000
SPCH-92521-EVAL OF SPEECH FLUENCY 1 1.000000 51.0500 51.0500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 48 50.000000 2452.5400 49.0508
SPCH-92524-BEHAV & QUAL ANALYSIS OF VOICE AND RES 8 9.000000 459.4500 51.0500
SPCH-92610-EVAL OF ORAL,PHARYNGEAL SWALLOWING FUNC 3 5.000000 244.7000 48.9400
Subtotal (Total Children Is Unduplicated) 1233 3749.909894 246778.9100 65.8093
-----------------------------------------------------------------------------------------------------------------------
EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 9 22.000000 7510.5700 341.3895
AUD-92592TS-AUDIOLOGY SERVICES (Monaural) 1 1.000000 50.0000 50.0000
AUD-92593TS-AUDIOLOGY SERVICES (Biaural) 3 3.000000 150.0000 50.0000
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 1 0.500000 25.0000 50.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 12 3.750000 187.5000 50.0000
CONIP-CONIP-CONSULT, ITDS PHONE 7 3.000000 75.0000 25.0000
CONOP-CONOP-CONSULT, OT, PHONE 1 0.500000 12.5000 25.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 1 1.000000 50.0000 50.0000
CONSP-CONSP-CONSULT, SLP, PHONE 2 1.000000 25.0000 25.0000
COUN-H2019HR-INDIVIDUAL/FAMILY THERAPY 3 5.000000 366.6000 73.3200
DSTT-DSTT-DIRECT SERVICE COORDINATOR TRAVEL 3 2.000000 0.0000 0.0000
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 4 5.000000 125.0000 25.0000
EIIF-96154-HEALTH AND BEHAVIOR INTERVENTION 2 59.500000 2975.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 1404 9111.700000 453702.5000 49.7934
INTR-T1013-INTERPRETER 6 23.250000 1162.5000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 61 90.000000 900.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 436 2131.101786 146324.3195 68.6613
OCCT-97530HM-OT SESSION BY OT ASST 130 657.756234 36851.4300 56.0260
PHY-97110-PT SESSION BY LICENSED PT 455 2461.362195 168187.9298 68.3312
PHY-97110HM-PT SESSION BY PT ASST 33 219.186798 12528.7158 57.1600
SENS-HA_INS-SENSORY AID INSURANCE PER EAR 1 1.000000 18.0000 18.0000
SENS-V5014-*HEARING AID REPAIR BY MANUFACTURER 1 2.000000 228.0000 114.0000
SENS-V5050-IN EAR MONAURAL HEARING AID 2 4.000000 912.0000 228.0000
SENS-V5264-EARMOLD 3 6.000000 108.0000 18.0000
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 973 5327.074719 366344.1893 68.7702
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 3 18.500000 1058.2000 57.2000
SPL-92508-GROUP SPL SESSION PER CHILD 16 27.250000 378.2300 13.8800
TRAV-TRAVS-Travel by mile 48 983.000000 437.3000 0.4449
Subtotal (Total Children Is Unduplicated) 2930 21170.43173 1200693.4844 56.7156
-----------------------------------------------------------------------------------------------------------------------
CMS/EIP Fiscal Report Statewide
Services beginning 01/01/2019 ending 03/31/2019 Date of Report:05/04/2019 Page: 2
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
Total 25011.591626 1450719.1444 58.0019
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 3660
-----------------------------------------------------------------------------------------------------------------------
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 2947 2973.250000 161731.1100 161731.1100
D 26 26.000000 1407.2000 0.0000
S 85 86.000000 5574.3100 0.0000
H 435 506.500000 34100.1300 0.0000
T 70 71.500000 4295.0300 4295.0300
285 311.500000 18373.2900 0.0000
Other 30 48.500000 3345.0000 0.0000
---------------------------------------------------------
Total 3878 4023.250000 228826.0700 166026.1400
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 552 453.000000 31602.5400 31560.1300
50 37.750000 2346.7300 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 602 490.750000 33949.2700 31560.1300
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 102 101.250000 6132.4200 6132.4200
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 5 5.000000 336.8100 336.8100
T 0 0.000000 0.0000 0.0000
159 158.500000 8903.8430 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 266 264.750000 15373.0730 6469.2300
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 127 265.000000 23672.6700 16901.0500
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 4 22.500000 1293.0800 0.0000
T 0 0.000000 0.0000 0.0000
94 91.500000 11197.8000 0.0000
Other 58 126.750000 8240.8300 0.0000
---------------------------------------------------------
Total 283 505.750000 44404.3800 16901.0500
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 23 49.500000 3468.7800 3536.2800
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
121 229.750000 15735.9000 16138.8200
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 144 279.250000 19204.6800 19675.1000
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 2515 2139.000000 117251.0400 117251.0400
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
2374 1981.750000 117581.2000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 4889 4120.750000 234832.2400 117251.0400
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 110 238.250000 14417.1700 14417.1700
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
11 9.000000 542.9600 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 121 247.250000 14960.1300 14417.1700
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 479 750.500000 48238.4500 48247.7800
D 23 23.000000 1643.1200 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
339 791.000000 55443.9600 10040.8400
Other 43 69.500000 5212.5000 0.0000
---------------------------------------------------------
Total 884 1634.000000 110538.0300 58288.6200
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 348 517.500000 29690.5500 29690.5500
D 4 4.000000 74.2700 0.0000
S 5 13.000000 928.7200 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
935 1974.250000 133269.6300 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 1292 2508.750000 163963.1700 29690.5500
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 250 946.500000 64055.8800 64055.8800
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
32 76.000000 4763.5200 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 282 1022.500000 68819.4000 64055.8800
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 34 40.250000 2530.2700 1712.7400
D 29 34.000000 1752.2500 0.0000
S 0 0.000000 0.0000 0.0000
H 75 92.000000 6068.3600 90.0000
T 712 1138.250000 70818.0700 65186.9500
419 680.750000 40752.4700 30.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 1269 1985.250000 121921.4200 67019.6900
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 20 19.028672 1040.7400 1682.9700
D 19 20.085585 1063.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 5 5.000000 271.4400 271.4400
T 32 32.000000 2152.0600 2152.0600
880 939.385742 54468.7000 0.0000
Other 42 49.750000 2838.5200 0.0000
---------------------------------------------------------
Total 998 1065.249999 61834.4600 4106.4700
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 3 3.000000 214.3200 308.1600
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 49 48.000000 2614.4000 2614.4000
T 116 117.000000 6394.8100 6394.8100
917 1848.420000 48014.5100 0.0000
Other 24 25.830000 1689.7200 0.0000
---------------------------------------------------------
Total 1109 2042.250000 58927.7600 9317.3700
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 786 748.427339 49277.7400 49277.7400
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 15 30.000000 2250.0000 0.0000
T 0 0.000000 0.0000 0.0000
763 662.414288 43865.6014 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 1564 1440.841627 95393.3414 49277.7400
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 19 9.500000 678.6800 678.6800
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 666 2231.000000 111860.1000 111860.1000
545 1140.500000 65232.9400 44160.2000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 1230 3381.000000 177771.7200 156698.9800