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: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 13500 15156.75000 560698.0000 36.9933
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 8287 8090.500000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 9272 52733.28056 1950245.3800 36.9832
Subtotal (Total Children Is Unduplicated) 20217 75980.53056 2510943.3800 33.0472
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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 83 86.000000 1695.0600 19.7100
AUDE-92553-PURE TONE AUDIOMETRY AIR & BONE 3 3.000000 70.4700 23.4900
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 84 88.000000 1220.5600 13.8700
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 85 89.000000 808.1200 9.0800
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 87 92.000000 2548.3800 27.6998
AUDE-92586-AUD EVOKED RESPONSE (LIMITED) 1 2.000000 52.7600 26.3800
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 44 45.000000 751.5000 16.7000
AUDE-92588-OTOACOUSTIC EMISSIONS (COMP) 16 16.000000 358.4000 22.4000
BEHV-H2014BA-BEHAVIOR ANALYSIS-ASSOCIATE 4 10.000000 487.6000 48.7600
EVAL-96111-DEVELOPMENTAL EVALUATION 77 88.250000 4412.5000 50.0000
EXIT-EXIT-EXIT ASSESSMENT 1009 1616.250000 80535.0000 49.8283
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 42 67.700000 5077.5000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 18 23.000000 1725.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 12 19.500000 1462.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 32 45.000000 3375.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 45 60.500000 3357.7500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 623 1022.212865 76504.6600 74.8422
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 285 436.848767 32403.6600 74.1759
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 132 212.740000 15955.0000 74.9976
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 893 1309.000000 72399.7500 55.3092
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 313 503.200000 35065.0000 69.6840
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 39 39.000000 2297.4900 58.9100
MED-99204-OUTPATIENT VISIT, NEW, 45 MINS 13 13.000000 1082.7700 83.2900
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 4 4.000000 93.6800 23.4200
OCTF-97168-OT RE-EVAL EST PLAN CARE 2 1.804100 92.1000 51.0504
OCTH-97165-OT EVAL LOW COMPLEXITY 2 2.000000 102.1000 51.0500
OCTH-97166-OT EVAL MODERATE COMPLEXITY 14 14.000000 714.7000 51.0500
OCTH-97167-OT EVAL HIGH COMPLEXITY 33 33.000000 1670.0300 50.6070
PSTF-97164-PT RE-EVAL EST PLAN CARE 5 5.000000 255.2500 51.0500
PSTH-97161-PT EVAL LOW COMPLEXITY 3 3.000000 145.1700 48.3900
PSTH-97162-PT EVAL MODERATE COMPLEXITY 4 4.000000 204.2000 51.0500
PSTH-97163-PT EVAL HIGH COMPLEXITY 16 16.000000 798.8200 49.9263
SCREEN-T1023-SCREENING 88 94.000000 4700.0000 50.0000
SPCH-92522-EVAL OF SPCH SOUND PROD 2 2.000000 102.1000 51.0500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 53 53.000000 2705.6500 51.0500
SPCH-92524-BEHAV & QUAL ANALYSIS OF VOICE AND RES 15 15.000000 765.7500 51.0500
Subtotal (Total Children Is Unduplicated) 2825 6160.005732 357256.9800 57.9962
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 49 95.000000 21656.6800 227.9651
AUD-92592TS-AUDIOLOGY SERVICES (Monaural) 1 1.000000 50.0000 50.0000
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 1544 1889.500000 93400.0000 49.4311
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 97 75.750000 1881.2500 24.8350
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 1909 3001.750000 149562.5000 49.8251
CONIP-CONIP-CONSULT, ITDS PHONE 228 225.500000 5625.0000 24.9446
CONOF-CONOF-CONSULT, OT, FACE TO FACE 739 1040.250000 51925.0000 49.9159
CONOP-CONOP-CONSULT, OT, PHONE 122 128.500000 3212.5000 25.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 784 949.500000 47275.0000 49.7894
CONPP-CONPP-CONSULT, PT, PHONE 21 17.750000 443.7500 25.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 1489 1871.250000 93475.0000 49.9532
CONSP-CONSP-CONSULT, SLP, PHONE 150 134.500000 3362.5000 25.0000
COUN-H2019HR-INDIVIDUAL/FAMILY THERAPY 10 27.000000 1979.6400 73.3200
DSTT-DSTT-DIRECT SERVICE COORDINATOR TRAVEL 2262 4908.000000 0.0000 0.0000
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 21 94.500000 2362.5000 25.0000
EIIF-96154-HEALTH AND BEHAVIOR INTERVENTION 1 18.000000 900.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 2746 17910.65000 891973.4100 49.8013
INTR-T1013-INTERPRETER 482 1573.250000 73497.6900 46.7171
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 13530 107656.0000 1074025.9210 9.9765
OCCT-97530-OT SESSION BY LICENSED OT 398 1881.648200 133483.5034 70.9397
OCCT-97530HM-OT SESSION BY OT ASST 118 487.744276 27870.3800 57.1414
PHY-97110-PT SESSION BY LICENSED PT 464 2270.387800 160617.5900 70.7446
PHY-97110HM-PT SESSION BY PT ASST 29 92.438500 5226.6242 56.5416
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 924 5034.949496 356233.7470 70.7522
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 2 6.000000 343.2000 57.2000
SPL-92508-GROUP SPL SESSION PER CHILD 5 9.000000 124.9200 13.8800
TRAV-TRAVS-Travel by mile 6155 510970.0000 225238.6300 0.4408
Subtotal (Total Children Is Unduplicated) 16796 662369.8183 3425746.9356 5.1720
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Total 744510.354564 6293947.2956 8.4538
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Number of Children (Unduplicated) With at Least One Service 25424
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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 18173 82475.000000 239443.7500 239443.7500
D 254 1476.000000 2764.2700 0.0000
S 339 1631.500000 5188.4800 0.0000
H 3 1.000000 37.0000 0.0000
T 469 2297.250000 5569.9700 5569.9700
6964 4515.750000 142520.6200 20.0000
Other 6 10.000000 652.5000 0.0000
---------------------------------------------------------
Total 26208 92406.500000 396176.5900 245033.7200
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 5402 15724.500000 112362.6000 112187.2600
316 1963.250000 6114.7800 0.0000
Other 5015 16919.250000 85227.0800 0.0000
---------------------------------------------------------
Total 10733 34607.000000 203704.4600 112187.2600
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 4394 44455.500000 104798.7100 104798.7100
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 423 3039.750000 18514.3700 18514.3700
T 0 0.000000 0.0000 0.0000
12704 52878.750000 310066.5700 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 17521 100374.000000 433379.6500 123313.0800
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 3393 13117.250000 229749.5300 229749.5300
D 8 9.750000 360.7500 0.0000
S 0 0.000000 0.0000 0.0000
H 15 38.500000 1802.8500 1774.2500
T 0 0.000000 0.0000 0.0000
4993 4714.000000 188303.4900 0.0000
Other 2 5.000000 251.0500 200.0000
---------------------------------------------------------
Total 8411 17884.500000 420467.6700 231723.7800
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 663 10107.500000 23214.1600 22895.8300
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
4843 26130.250000 114913.1800 62174.6700
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 5506 36237.750000 138127.3400 85070.5000
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 8818 8744.250000 120260.5500 120260.5500
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
12043 8501.500000 198509.8300 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 20861 17245.750000 318770.3800 120260.5500
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 2372 7905.750000 150461.6700 150898.6700
D 45 33.250000 1306.2500 0.0000
S 49 36.250000 1313.5000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
7607 4816.000000 148448.2500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 10073 12791.250000 301529.6700 150898.6700
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 16729 113365.250000 675968.2800 675968.2800
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 4 16.000000 624.0000 468.0000
564 7489.750000 23013.6600 0.0000
Other 4 7.500000 523.5000 0.0000
---------------------------------------------------------
Total 17301 120878.500000 700129.4400 676436.2800
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 10977 33015.000000 841432.3700 841460.1200
D 58 60.000000 1766.6900 0.0000
S 151 285.500000 6092.2600 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
5865 4672.000000 155111.2500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 17051 38032.500000 1004402.5700 841460.1200
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 1199 8339.750000 69119.1000 69155.1100
D 2 2.000000 111.0000 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
2657 2179.500000 70335.6500 135.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 3858 10521.250000 139565.7500 69290.1100
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 0 0.000000 0.0000 0.0000
D 29 30.250000 1505.2500 525.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 5769 58702.250000 154676.8200 149515.1000
2716 1748.250000 47120.6500 316.7700
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 8514 60480.750000 203302.7200 150356.8700
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 1 1.000000 50.0000 50.0000
D 10 15.500000 725.5000 0.0000
S 0 0.000000 0.0000 0.0000
H 659 4165.500000 8092.5800 8092.5800
T 1837 13857.000000 21968.6500 21968.6500
13994 35593.250000 184820.0300 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 16501 53632.250000 215656.7600 30111.2300
Center 54
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 1 1.000000 50.0000 0.0000
P 0 0.000000 0.0000 0.0000
D 26 20.500000 927.5000 0.0000
S 0 0.000000 0.0000 0.0000
H 2022 12445.000000 23882.9200 23882.9200
T 4785 28254.520000 55691.1800 55691.1800
16376 33840.980000 206430.0610 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 23210 74562.000000 286981.6610 79574.1000
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 8162 15209.962109 167960.9846 167960.9800
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
7116 30993.892455 1059040.7800 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 15278 46203.854564 1227001.7646 167960.9800
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 88 234.000000 3435.1800 3435.1800
H 0 0.000000 0.0000 0.0000
T 3769 25304.000000 185023.8900 184952.4500
2974 3114.500000 116291.8000 51.0500
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 6831 28652.500000 304750.8700 188438.6800