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
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 13502 15159.75000 560809.0000 36.9933
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 8432 8184.250000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 24974 99978.64931 3697188.2744 36.9798
Subtotal (Total Children Is Unduplicated) 26131 123322.6493 4257997.2744 34.5273
-----------------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
ASTE-ASTE-ASSISTIVE TECHNOLOGY EVAL 27 27.000000 1309.5000 48.5000
AUDE-92552-PURE TONE AUDIOMETRY -AIR ONLY 100 104.000000 2049.8400 19.7100
AUDE-92553-PURE TONE AUDIOMETRY AIR & BONE 6 7.000000 164.4300 23.4900
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 111 119.000000 1643.6300 13.8120
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 113 122.000000 1098.6800 9.0056
AUDE-92568-ACOUSTIC REFLEX TESTING (MEMR) 1 1.000000 9.9600 9.9600
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 116 125.000000 3438.9400 27.5115
AUDE-92585-AUD EVOKED RESPONSE (COMP) 1 1.000000 84.8400 84.8400
AUDE-92586-AUD EVOKED RESPONSE (LIMITED) 1 2.000000 52.7600 26.3800
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 55 56.000000 935.2000 16.7000
AUDE-92588-OTOACOUSTIC EMISSIONS (COMP) 22 22.000000 492.8000 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 9 31.000000 1511.5600 48.7600
EVAL-96111-DEVELOPMENTAL EVALUATION 83 106.750000 5337.5000 50.0000
EXIT-EXIT-EXIT ASSESSMENT 1029 1652.250000 82335.0000 49.8320
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 210 357.000000 26497.5000 74.2227
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 82 135.500000 9785.0000 72.2140
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 41 69.000000 5175.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 113 197.000000 15183.8200 77.0752
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 236 388.000000 21387.0000 55.1211
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 3224 5231.333332 390115.3060 74.5728
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 1390 2253.499996 167815.3500 74.4688
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 635 1060.009466 78904.2000 74.4373
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 4045 6508.999999 359824.7500 55.2811
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 1448 2436.666667 181698.7600 74.5686
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 91 91.000000 10233.1300 112.4520
MED-99204-OUTPATIENT VISIT, NEW, 45 MINS 18 18.000000 1499.2200 83.2900
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 18 18.000000 1608.6200 89.3678
NUTR-97802-NUTRITIONAL EVAL, INITIAL 3 14.000000 700.0000 50.0000
NUTR-97803-NUTRITIONAL EVAL, FOLLOW-UP 8 32.000000 1600.0000 50.0000
OCTF-97168-OT RE-EVAL EST PLAN CARE 24 24.000000 1199.8600 49.9942
OCTH-97165-OT EVAL LOW COMPLEXITY 8 8.000000 408.4000 51.0500
OCTH-97166-OT EVAL MODERATE COMPLEXITY 49 50.000000 2501.4500 50.0290
OCTH-97167-OT EVAL HIGH COMPLEXITY 110 111.000000 5633.7600 50.7546
PSTF-97164-PT RE-EVAL EST PLAN CARE 22 21.999999 1067.4200 48.5191
PSTH-97161-PT EVAL LOW COMPLEXITY 6 6.000000 298.3200 49.7200
PSTH-97162-PT EVAL MODERATE COMPLEXITY 19 19.000000 915.0400 48.1600
PSTH-97163-PT EVAL HIGH COMPLEXITY 82 82.000000 4168.1200 50.8307
SCREEN-T1023-SCREENING 181 190.000000 9500.0000 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 159 161.000000 8119.0900 50.4291
SPCH-92524-BEHAV & QUAL ANALYSIS OF VOICE AND RES 27 28.000000 1429.4000 51.0500
SPCH-92610-EVAL OF ORAL,PHARYNGEAL SWALLOWING FUNC 6 8.000000 391.5200 48.9400
Subtotal (Total Children Is Unduplicated) 7482 21904.00946 1408827.8260 64.3183
-----------------------------------------------------------------------------------------------------------------------
EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 57 118.000000 29242.3300 247.8164
AUD-92592TS-AUDIOLOGY SERVICES (Monaural) 2 2.000000 100.0000 50.0000
AUD-92593TS-AUDIOLOGY SERVICES (Biaural) 3 3.000000 150.0000 50.0000
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 1568 1930.750000 95462.5000 49.4432
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 115 92.750000 2306.2500 24.8652
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 1915 3009.000000 149925.0000 49.8255
CONIP-CONIP-CONSULT, ITDS PHONE 232 229.500000 5725.0000 24.9455
CONOF-CONOF-CONSULT, OT, FACE TO FACE 741 1045.250000 52175.0000 49.9163
CONOP-CONOP-CONSULT, OT, PHONE 123 129.000000 3225.0000 25.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 788 956.500000 47625.0000 49.7909
CONPP-CONPP-CONSULT, PT, PHONE 23 19.000000 475.0000 25.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 1502 1889.250000 94375.0000 49.9537
CONSP-CONSP-CONSULT, SLP, PHONE 150 135.500000 3387.5000 25.0000
COUN-H2019HR-INDIVIDUAL/FAMILY THERAPY 18 47.000000 3446.0400 73.3200
DSTT-DSTT-DIRECT SERVICE COORDINATOR TRAVEL 2262 4910.000000 0.0000 0.0000
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 113 4912.250000 122806.2500 25.0000
EIIF-96154-HEALTH AND BEHAVIOR INTERVENTION 2 77.500000 3875.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 10050 73923.00000 3689445.5300 49.9093
INTR-T1013-INTERPRETER 488 1600.000000 74835.1900 46.7720
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 13531 107775.0000 1075215.9210 9.9765
OCCT-97530-OT SESSION BY LICENSED OT 1312 6978.249986 491178.1029 70.3870
OCCT-97530HM-OT SESSION BY OT ASST 484 2454.999983 139625.1800 56.8738
PHY-97110-PT SESSION BY LICENSED PT 1447 8198.499995 575973.9798 70.2536
PHY-97110HM-PT SESSION BY PT ASST 222 1196.125298 68313.3600 57.1122
SENS-HA_INS-SENSORY AID INSURANCE PER EAR 1 1.000000 18.0000 18.0000
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
Eligibility Filter:Program Patients
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
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 2666 15892.52422 1116321.3063 70.2419
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 74 226.000000 12934.3200 57.2315
SPL-92508-GROUP SPL SESSION PER CHILD 39 78.250000 1086.1100 13.8800
TRAV-TRAVS-Travel by mile 6392 566046.0000 249536.8900 0.4408
Subtotal (Total Children Is Unduplicated) 17642 803887.8995 8110032.7600 10.0885
-----------------------------------------------------------------------------------------------------------------------
Total 949114.558246 13776857.8604 14.5155
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 28424
-----------------------------------------------------------------------------------------------------------------------
Center 01
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 656 429.250000 18310.2300 0.0000
P 21230 85557.250000 406577.9100 406234.6600
D 331 1552.500000 6833.4900 0.0000
S 601 1893.250000 20872.0500 0.0000
H 8808 6369.000000 280119.2600 208951.7500
T 544 2374.250000 10191.7500 10173.2500
7288 4863.000000 162792.9100 20.0000
Other 281 436.000000 27995.0000 138.7500
---------------------------------------------------------
Total 39739 103474.500000 933692.6000 625518.4100
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 5959 16185.500000 144565.1400 144347.3900
370 2008.500000 9024.0100 0.0000
Other 7306 18451.250000 152064.5800 0.0000
---------------------------------------------------------
Total 13635 36645.250000 305653.7300 144347.3900
Center 03
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 52 29.750000 1100.7500 0.0000
U 0 0.000000 0.0000 0.0000
B 3968 2815.500000 121118.7500 0.0000
P 4644 44704.250000 117768.3800 117768.3800
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 428 3044.750000 18851.1800 18851.1800
T 1 0.250000 9.2500 0.0000
12930 53102.250000 323488.3030 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 22023 103696.750000 582336.6130 136619.5600
Center 04
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 67 83.250000 3080.2500 0.0000
U 0 0.000000 0.0000 0.0000
B 2120 3046.500000 119318.5800 0.0000
P 4281 14537.000000 301300.9800 290837.6100
D 8 9.750000 360.7500 0.0000
S 2 5.000000 185.0000 0.0000
H 2312 9321.500000 475877.0600 1774.2500
T 0 0.000000 0.0000 0.0000
7155 11965.000000 436518.4500 0.0000
Other 60 131.750000 8491.8800 200.0000
---------------------------------------------------------
Total 16005 39099.750000 1345132.9500 292811.8600
Center 05
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 42 50.500000 3242.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 2476 1641.750000 62438.2500 0.0000
P 690 10165.500000 27016.1900 26815.3600
D 10 3.500000 129.5000 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
4977 26370.750000 131085.8300 78413.4900
Other 1 1.000000 37.0000 0.0000
---------------------------------------------------------
Total 8196 38233.000000 223949.2700 105228.8500
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 11333 10883.250000 237511.5900 237511.5900
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
26347 20462.250000 796406.6000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 37680 31345.500000 1033918.1900 237511.5900
Center 07
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 6 3.000000 111.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 1568 1354.250000 56144.8000 55.5000
P 5214 10708.000000 275490.5900 275157.3400
D 46 33.750000 1324.7500 0.0000
S 153 111.750000 4122.0000 0.0000
H 1 1.000000 37.0000 37.0000
T 0 0.000000 0.0000 0.0000
7690 4889.250000 151861.4600 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 14678 17101.000000 489091.6000 275249.8400
Center 09
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 16 13.500000 632.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 347 348.000000 17142.5000 1683.2500
P 25352 176596.000000 1157830.2800 1171416.2800
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 4 16.000000 624.0000 468.0000
3388 15919.500000 513771.4900 158911.6800
Other 240 390.000000 28548.0000 0.0000
---------------------------------------------------------
Total 29370 193306.000000 1720191.8900 1332479.2100
Center 10
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 208 144.000000 5328.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 2000 1529.750000 60098.5000 46.2500
P 15403 37238.250000 1036313.3100 1032301.7000
D 378 378.500000 17905.7800 0.0000
S 1593 1670.500000 67415.9800 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
11160 20126.750000 1011578.9100 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 30742 61087.750000 2198640.4800 1032347.9500
Center 51
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 2 1.500000 74.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 1091 803.250000 30926.3200 0.0000
P 1451 9296.500000 133782.8600 133210.9900
D 13 10.000000 407.0000 0.0000
S 1 0.250000 9.2500 0.0000
H 1 0.500000 18.5000 0.0000
T 0 0.000000 0.0000 0.0000
3235 3840.250000 169199.3300 135.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 5794 13952.250000 334417.2600 133345.9900
Center 52
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 5 3.000000 143.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 1339 1239.750000 56386.7300 0.0000
P 1603 1555.750000 74587.8500 73053.5600
D 101 110.750000 5714.8200 605.0000
S 5 2.500000 92.5000 0.0000
H 280 321.750000 18635.2500 623.3500
T 6511 59891.750000 228858.5600 217471.4400
4239 4537.250000 213954.9900 362.1100
Other 2 3.000000 111.0000 55.5000
---------------------------------------------------------
Total 14085 67665.500000 598485.2000 292170.9600
Center 53
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 7 8.250000 381.2500 0.0000
U 0 0.000000 0.0000 0.0000
B 1344 1283.000000 59727.9900 118.5000
P 1832 1703.778672 78538.6100 77898.8600
D 53 54.835585 2841.5200 0.0000
S 63 53.750000 1942.5000 1850.0000
H 668 4174.500000 8629.4300 8522.2700
T 1869 13889.000000 24120.7100 24120.7100
16900 38610.635742 349479.5100 0.0000
Other 47 54.000000 3121.6500 0.0000
---------------------------------------------------------
Total 22783 59831.749999 528783.1700 112510.3400
Center 54
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 10 8.750000 397.1900 0.0000
U 0 0.000000 0.0000 0.0000
B 2273 1946.750000 90936.5400 68.5000
P 2991 2402.500000 103976.4900 103560.7200
D 72 56.500000 2573.8500 0.0000
S 185 103.750000 3820.2500 3820.2500
H 2071 12493.000000 26497.3200 26497.3200
T 4904 28376.020000 62335.7400 62335.7400
21156 39648.150000 450600.8010 0.0000
Other 45 47.080000 2813.1000 0.0000
---------------------------------------------------------
Total 33707 85082.500000 743951.2810 196282.5300
Center 55
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 2329 2123.275135 90330.1800 150.0000
P 10503 17248.433063 271484.1890 271357.6700
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 22 44.000000 3250.0000 0.0000
T 0 0.000000 0.0000 0.0000
12170 36086.100049 1374941.1974 0.0000
Other 3 5.000000 185.0000 185.0000
---------------------------------------------------------
Total 25027 55506.808247 1740190.5664 271692.6700
Center 57
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 1151 1476.750000 59536.7500 166.5000
P 2161 2620.500000 108814.5800 107126.9300
D 1 1.000000 75.0000 75.0000
S 88 234.000000 3435.1800 3435.1800
H 0 0.000000 0.0000 0.0000
T 4435 27535.000000 296883.9900 296812.5500
5521 11043.500000 528802.6500 388328.1600
Other 18 175.500000 874.9100 856.4100
---------------------------------------------------------
Total 13375 43086.250000 998423.0600 796800.7300