CMS/EIP Fiscal Report Statewide
Services beginning 07/01/2019 ending 09/30/2019 Date of Report:11/04/2019 Page: 1
List order: No List
Payclass Filters:GR
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 12460 13626.00000 504060.5000 36.9926
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 7278 6896.250000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 8171 24338.50000 899969.5000 36.9772
Subtotal (Total Children Is Unduplicated) 18748 44860.75000 1404030.0000 31.2975
-----------------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
ASTE-ASTE-ASSISTIVE TECHNOLOGY EVAL 29 31.000000 1503.5000 48.5000
AUDE-92552-PURE TONE AUDIOMETRY -AIR ONLY 40 41.000000 803.6700 19.6017
AUDE-92553-PURE TONE AUDIOMETRY AIR & BONE 1 1.000000 23.4900 23.4900
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 45 46.000000 667.6200 14.5135
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 47 49.000000 459.3500 9.3745
AUDE-92568-ACOUSTIC REFLEX TESTING (MEMR) 1 1.000000 9.9600 9.9600
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 44 45.000000 1288.7100 28.6380
AUDE-92585-AUD EVOKED RESPONSE (COMP) 2 2.000000 154.2700 77.1350
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 18 18.000000 271.3500 15.0750
AUDE-92588-OTOACOUSTIC EMISSIONS (COMP) 17 18.000000 375.8400 20.8800
AUDE-V5010-ASSESSMENT FOR HEARING AID 1 1.000000 45.0000 45.0000
AUDE-V5090-DISPENSING FEE PER HEARING AID 1 2.000000 230.0000 115.0000
EVAL-96111-DEVELOPMENTAL EVALUATION 109 125.500000 6275.0000 50.0000
EXIT-EXIT-EXIT ASSESSMENT 1020 1582.500000 78900.0000 49.8578
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 26 38.136800 2860.2600 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 12 15.500000 1162.5000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 6 9.000000 675.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 18 31.000000 2325.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 52 74.500000 4134.7500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 434 708.253868 52906.3000 74.6996
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 176 262.430404 19682.2801 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 144 226.500000 16987.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 690 1010.500000 56082.7500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 263 419.286700 31305.5700 74.6639
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 20 20.000000 1178.2000 58.9100
MED-99204-OUTPATIENT VISIT, NEW, 45 MINS 2 2.000000 166.5800 83.2900
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 4 4.000000 93.6800 23.4200
MED-99214-OUTPATIENT VISIT, EST, 25 MINS 1 1.000000 36.4900 36.4900
OCTF-97168-OT RE-EVAL EST PLAN CARE 3 3.000000 153.1500 51.0500
OCTH-97165-OT EVAL LOW COMPLEXITY 2 2.000000 102.1000 51.0500
OCTH-97166-OT EVAL MODERATE COMPLEXITY 16 16.000000 816.8000 51.0500
OCTH-97167-OT EVAL HIGH COMPLEXITY 45 44.510284 2228.3100 50.0628
PSTF-97164-PT RE-EVAL EST PLAN CARE 4 4.000000 204.2000 51.0500
PSTH-97162-PT EVAL MODERATE COMPLEXITY 8 8.000000 408.4000 51.0500
PSTH-97163-PT EVAL HIGH COMPLEXITY 29 31.000000 1541.5000 49.7258
SCREEN-T1023-SCREENING 94 105.000000 5250.0000 50.0000
SPCH-92522-EVAL OF SPCH SOUND PROD 4 4.000000 159.2000 39.8000
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 71 72.174535 3593.1900 49.7847
SPCH-92524-BEHAV & QUAL ANALYSIS OF VOICE AND RES 13 13.000000 663.6500 51.0500
Subtotal (Total Children Is Unduplicated) 2490 5087.792591 295725.1201 58.1244
-----------------------------------------------------------------------------------------------------------------------
EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 26 58.000000 12442.5900 214.5274
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 1522 1898.250000 94246.4400 49.6491
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 101 79.000000 1975.0000 25.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 1896 2641.250000 131937.5000 49.9527
CONIP-CONIP-CONSULT, ITDS PHONE 211 196.750000 4912.4500 24.9680
CONOF-CONOF-CONSULT, OT, FACE TO FACE 1007 1039.250000 51950.0000 49.9880
CONOP-CONOP-CONSULT, OT, PHONE 75 98.750000 2468.7500 25.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 737 700.250000 35000.0000 49.9821
CONPP-CONPP-CONSULT, PT, PHONE 22 11.250000 281.2500 25.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 1382 1532.750000 76625.0000 49.9918
CONSP-CONSP-CONSULT, SLP, PHONE 159 133.750000 3343.7500 25.0000
COUN-H2019HR-INDIVIDUAL/FAMILY THERAPY 1 2.000000 146.6400 73.3200
DSTT-DSTT-DIRECT SERVICE COORDINATOR TRAVEL 2112 5082.750000 0.0000 0.0000
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 31 114.000000 2850.0000 25.0000
EIIF-96154-HEALTH AND BEHAVIOR INTERVENTION 1 42.750000 2137.5000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 3225 22454.32000 1120079.7700 49.8826
INTR-T1013-INTERPRETER 421 1304.250000 63156.0000 48.4232
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 14010 116919.0000 1168388.6600 9.9931
OCCT-97530-OT SESSION BY LICENSED OT 403 1713.967657 120196.8300 70.1278
OCCT-97530HM-OT SESSION BY OT ASST 114 466.600700 26689.5600 57.2000
PHY-97110-PT SESSION BY LICENSED PT 444 2145.033035 149232.6000 69.5712
PHY-97110HM-PT SESSION BY PT ASST 29 117.676529 6220.6000 52.8619
SENS-HA_INS-SENSORY AID INSURANCE PER EAR 1 1.000000 525.0000 525.0000
SENS-V5014-*HEARING AID REPAIR BY MANUFACTURER 1 2.000000 228.0000 114.0000
SENS-V5050-IN EAR MONAURAL HEARING AID 1 2.000000 456.0000 228.0000
SENS-V5264-EARMOLD 2 4.000000 72.0000 18.0000
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 988 5392.527446 374640.7400 69.4741
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 1 1.500000 85.8000 57.2000
SPL-92508-GROUP SPL SESSION PER CHILD 9 30.000000 395.5800 13.1860
TRAV-TRAVS-Travel by mile 6075 511681.0000 224795.8800 0.4393
Subtotal (Total Children Is Unduplicated) 17061 675865.6254 3675479.8900 5.4382
CMS/EIP Fiscal Report Statewide
Services beginning 07/01/2019 ending 09/30/2019 Date of Report:11/04/2019 Page: 2
List order: No List
Payclass Filters:GR
Eligibility Filter:Part C (excluding not eligible)
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
-----------------------------------------------------------------------------------------------------------------------
Total 725814.167958 5375235.0101 7.4058
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 24393
-----------------------------------------------------------------------------------------------------------------------
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 19004 87810.000000 246190.3900 246006.0700
D 287 1328.500000 3514.7100 0.0000
S 523 1456.500000 12587.7800 0.0000
H 2 3.000000 171.4400 0.0000
T 779 2439.250000 12136.5100 12136.5100
6196 4049.500000 134916.8000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 26791 97086.750000 409517.6300 258142.5800
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 5395 14442.500000 114903.4400 114774.5000
130 641.750000 3270.9200 0.0000
Other 3950 16788.750000 66558.3800 0.0000
---------------------------------------------------------
Total 9475 31873.000000 184732.7400 114774.5000
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 2702 27006.750000 64911.5800 64911.5800
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 327 2997.750000 7358.7000 7358.7000
T 818 7229.500000 17240.1600 17240.1600
9023 38787.750000 204536.6500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 12870 76021.750000 294047.0900 89510.4400
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 4089 15898.750000 263782.1400 263698.6400
D 17 20.000000 843.7500 0.0000
S 0 0.000000 0.0000 0.0000
H 6 26.000000 260.0000 260.0000
T 0 0.000000 0.0000 0.0000
4430 3918.000000 154861.8000 0.0000
Other 1 3.000000 30.0000 30.0000
---------------------------------------------------------
Total 8543 19865.750000 419777.6900 263988.6400
Center 05
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 1 0.250000 9.2500 0.0000
P 6121 73223.000000 203800.0700 203800.0700
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
3226 7557.250000 60961.5000 14887.2500
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 9348 80780.500000 264770.8200 218687.3200
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 10395 10221.750000 202324.4600 202324.4600
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
11489 8086.500000 209556.7700 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 21884 18308.250000 411881.2300 202324.4600
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 3748 11691.250000 231482.9200 231510.6700
D 11 7.750000 299.7500 0.0000
S 49 24.000000 804.7500 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
6617 3974.536700 123220.1000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 10425 15697.536700 355807.5200 231510.6700
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 15693 122203.750000 649653.0700 649653.0700
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
226 3144.750000 14255.5000 0.0000
Other 1 1.000000 75.0000 0.0000
---------------------------------------------------------
Total 15920 125349.500000 663983.5700 649653.0700
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 11534 32686.500000 790595.1500 790595.1500
D 5 6.000000 60.0000 0.0000
S 113 179.750000 4975.7200 80.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
6302 4905.250000 161770.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 17954 37777.500000 957400.8700 790675.1500
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 1595 9145.250000 125214.0800 125214.0800
D 1 0.250000 9.2500 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
1379 1030.000000 35115.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 2975 10175.500000 160338.3300 125214.0800
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 3 30.250000 35.4000 35.4000
D 0 0.000000 0.0000 0.0000
S 96 69.000000 1896.2500 0.0000
H 0 0.000000 0.0000 0.0000
T 5265 52951.000000 134658.0600 129345.6000
1495 1046.500000 28048.5100 264.2600
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 6859 54096.750000 164638.2200 129645.2600
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 3 3.000000 77.7500 96.2500
D 7 6.500000 240.5000 0.0000
S 2 2.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 2693 17537.500000 31553.1700 31553.1700
13490 22475.750000 169017.3600 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 16195 40024.750000 200888.7800 31649.4200
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 1 0.250000 0.0000 27.7500
D 11 9.250000 502.6500 0.0000
S 2 2.000000 10.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 6124 34313.400000 69391.9200 69391.9200
18053 36078.250000 229180.4400 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 24191 70403.150000 299085.0100 69419.6700
Center 55
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 1 0.250000 9.2500 0.0000
P 7485 15660.999587 135666.1001 135666.1000
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
6503 5982.731671 136163.6100 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 13989 21643.981258 271838.9601 135666.1000
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 174 88.000000 6245.9400 6245.9400
H 0 0.000000 0.0000 0.0000
T 4300 23665.500000 202988.5000 202988.5100
3147 2956.000000 107292.1100 387.8600
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 7621 26709.500000 316526.5500 209622.3100