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: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 1 2.750000 101.7500 37.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 2 3.500000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 53 103.500000 3829.5000 37.0000
Subtotal (Total Children Is Unduplicated) 54 109.750000 3931.2500 35.8200
-----------------------------------------------------------------------------------------------------------------------
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 7 18.500000 925.0000 50.0000
EXIT-EXIT-EXIT ASSESSMENT 2 2.000000 100.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 45 75.500000 5446.8500 72.1437
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 14 26.000000 1812.5000 69.7115
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 6 10.000000 750.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 30 50.000000 4158.8200 83.1764
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 44 78.500000 4209.7500 53.6274
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 768 1302.420467 95730.3960 73.5019
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 234 419.651229 30794.1900 73.3804
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 148 257.269466 18738.2000 72.8349
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 855 1457.499999 79882.7500 54.8081
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 368 605.666667 47221.2600 77.9658
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 26 26.000000 6403.9800 246.3069
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) 1556 4661.203727 309465.7760 66.3918
-----------------------------------------------------------------------------------------------------------------------
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 1406 9131.700000 454702.5000 49.7939
INTR-T1013-INTERPRETER 8 26.750000 1337.5000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 65 94.000000 940.0000 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 52 1043.000000 463.9800 0.4449
Subtotal (Total Children Is Unduplicated) 2938 21257.93173 1201935.1644 56.5406
-----------------------------------------------------------------------------------------------------------------------
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:Program Patients
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Total 26028.885459 1515332.1904 58.2173
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 3991
-----------------------------------------------------------------------------------------------------------------------
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 2994 3036.750000 165268.6100 165268.6100
D 26 26.000000 1407.2000 0.0000
S 86 86.500000 5611.8100 0.0000
H 463 545.000000 36782.8800 0.0000
T 73 76.500000 4603.2800 4603.2800
295 328.000000 19484.0400 0.0000
Other 39 61.000000 4204.5000 0.0000
---------------------------------------------------------
Total 3976 4159.750000 237362.3200 169871.8900
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 557 461.000000 32202.5400 32160.1300
54 45.250000 2909.2300 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 611 506.250000 35111.7700 32160.1300
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 136 273.500000 25394.8000 18623.1800
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
123 120.000000 13764.0500 0.0000
Other 58 126.750000 8240.8300 0.0000
---------------------------------------------------------
Total 321 542.750000 48692.7600 18623.1800
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
2427 2050.250000 122114.2000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 4942 4189.250000 239365.2400 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 530 832.000000 53651.6500 53660.9800
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
368 837.000000 58522.7100 10190.8400
Other 56 87.500000 6562.5000 0.0000
---------------------------------------------------------
Total 977 1779.500000 120379.9800 63851.8200
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
994 2093.750000 141188.8800 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 1351 2628.250000 171882.4200 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 40 51.250000 3287.0200 2099.3600
D 42 54.500000 2929.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 97 130.500000 8838.8600 90.0000
T 737 1181.750000 73670.9600 67956.3400
441 717.000000 42892.8300 30.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 1357 2135.000000 131618.6700 70175.7000
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 22 23.028672 1301.7400 2007.2300
D 21 23.085585 1258.7500 0.0000
S 0 0.000000 0.0000 0.0000
H 7 7.500000 429.6900 429.6900
T 32 32.000000 2152.0600 2152.0600
914 993.135742 57825.7000 0.0000
Other 43 51.250000 2951.0200 0.0000
---------------------------------------------------------
Total 1039 1129.999999 65918.9600 4588.9800
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 119 121.500000 6644.5600 6644.5600
960 1972.420000 51933.9400 0.0000
Other 26 28.830000 1885.4700 0.0000
---------------------------------------------------------
Total 1157 2173.750000 63292.6900 9567.1200
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 793 762.427339 50327.7400 50327.7400
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
791 711.708121 47359.6374 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 1606 1518.135460 100937.3774 50327.7400
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
611 1212.000000 69873.9400 44682.2000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 1296 3452.500000 182412.7200 157220.9800