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: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 9 6.750000 249.7500 37.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 3 1.750000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 114 227.500000 8408.2500 36.9593
Subtotal (Total Children Is Unduplicated) 117 236.000000 8658.0000 36.6864
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Screening, Eval, and Assessment,Class #02
AUDE-92552-PURE TONE AUDIOMETRY -AIR ONLY 14 14.000000 275.0400 19.6457
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 20 21.000000 321.2300 15.2967
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 22 23.000000 205.2100 8.9222
AUDE-92568-ACOUSTIC REFLEX TESTING (MEMR) 3 3.000000 29.8800 9.9600
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 22 22.000000 629.8700 28.6305
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 7 7.000000 110.7300 15.8186
AUDE-92588-OTOACOUSTIC EMISSIONS (COMP) 8 8.000000 167.2300 20.9038
EXIT-EXIT-EXIT ASSESSMENT 5 7.000000 350.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 33 52.863200 3919.7400 74.1487
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 6 14.000000 1050.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 6 8.500000 587.5000 69.1176
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 28 56.000000 4200.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 37 71.500000 3968.2500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 560 979.982136 72058.1901 73.5301
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 171 307.569603 22403.4503 72.8403
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 162 261.000000 19274.4900 73.8486
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 560 987.000000 54443.8000 55.1609
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 259 436.697834 32258.1500 73.8684
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 8 8.000000 2432.0000 304.0000
MED-99204-OUTPATIENT VISIT, NEW, 45 MINS 2 2.000000 1014.0000 507.0000
OCTF-97168-OT RE-EVAL EST PLAN CARE 10 10.000000 472.1600 47.2160
OCTH-97165-OT EVAL LOW COMPLEXITY 3 3.000000 90.8200 30.2733
OCTH-97166-OT EVAL MODERATE COMPLEXITY 9 9.000000 459.4500 51.0500
OCTH-97167-OT EVAL HIGH COMPLEXITY 28 29.489716 1398.3500 47.4182
PSTF-97164-PT RE-EVAL EST PLAN CARE 8 8.000000 291.2200 36.4025
PSTH-97161-PT EVAL LOW COMPLEXITY 2 2.000000 102.1000 51.0500
PSTH-97162-PT EVAL MODERATE COMPLEXITY 12 12.000000 571.7700 47.6475
PSTH-97163-PT EVAL HIGH COMPLEXITY 26 28.000000 1327.3000 47.4036
SCREEN-T1023-SCREENING 12 12.000000 600.0000 50.0000
SPCH-92521-EVAL OF SPEECH FLUENCY 3 4.000000 153.1500 38.2875
SPCH-92522-EVAL OF SPCH SOUND PROD 3 3.000000 153.1500 51.0500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 66 64.825465 3294.3400 50.8186
SPCH-92524-BEHAV & QUAL ANALYSIS OF VOICE AND RES 7 7.000000 357.3500 51.0500
SPCH-92610-EVAL OF ORAL,PHARYNGEAL SWALLOWING FUNC 2 2.000000 97.8800 48.9400
Subtotal (Total Children Is Unduplicated) 1196 3484.427954 229067.8004 65.7404
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 4 11.000000 1109.1500 100.8318
AUDE-V5160-DISPENSING FEE BINAURAL 1 1.000000 59.0000 59.0000
CONIP-CONIP-CONSULT, ITDS PHONE 2 2.000000 50.0000 25.0000
CONSP-CONSP-CONSULT, SLP, PHONE 3 2.500000 62.5000 25.0000
DSTT-DSTT-DIRECT SERVICE COORDINATOR TRAVEL 4 3.500000 0.0000 0.0000
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 3 4.000000 100.0000 25.0000
EIIF-96154-HEALTH AND BEHAVIOR INTERVENTION 1 2.000000 100.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 1073 7383.390000 368320.2900 49.8850
INTR-T1013-INTERPRETER 1 3.000000 150.0000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 1 1.000000 10.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 385 2008.932400 135014.1100 67.2069
OCCT-97530HM-OT SESSION BY OT ASST 135 555.261886 31609.7600 56.9277
PHY-97110-PT SESSION BY LICENSED PT 394 2143.036953 144887.0000 67.6083
PHY-97110HM-PT SESSION BY PT ASST 36 158.918298 9083.7700 57.1600
SENS-V5264-EARMOLD 1 2.000000 36.0000 18.0000
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 931 5087.605391 346971.3400 68.1993
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 8 17.500000 1001.0000 57.2000
SPL-92508-GROUP SPL SESSION PER CHILD 9 25.500000 353.9400 13.8800
Subtotal (Total Children Is Unduplicated) 2504 17412.14493 1038917.8600 59.6663
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Total 21132.572882 1276643.6604 60.4112
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Number of Children (Unduplicated) With at Least One Service 3337
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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 2714 2738.750000 144145.5200 144145.5200
D 36 36.000000 1922.4400 0.0000
S 260 274.500000 17223.6900 0.0000
H 332 367.250000 24672.0800 0.0000
T 123 117.000000 6748.7000 6748.7000
121 125.250000 7254.4800 0.0000
Other 14 22.500000 1551.0000 0.0000
---------------------------------------------------------
Total 3600 3681.250000 203517.9100 150894.2200
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 431 372.000000 25057.5900 25057.1300
83 53.500000 3150.1200 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 514 425.500000 28207.7100 25057.1300
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 77 76.250000 3961.6500 3961.6500
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 2 2.000000 114.8200 114.8200
T 17 17.000000 952.5900 952.5900
142 126.250000 6379.3300 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 238 221.500000 11408.3900 5029.0600
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 108 252.000000 16461.5700 11451.5800
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 10 44.000000 2221.6000 0.0000
T 0 0.000000 0.0000 0.0000
92 86.500000 8949.0900 0.0000
Other 67 143.500000 9518.0900 0.0000
---------------------------------------------------------
Total 277 526.000000 37150.3500 11451.5800
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 119 251.000000 17533.6000 17533.6000
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
3 6.500000 357.1600 357.1600
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 122 257.500000 17890.7600 17890.7600
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 856 525.750000 35179.0100 35179.0100
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
1168 998.250000 66625.3400 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 2024 1524.000000 101804.3500 35179.0100
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 143 374.963300 24906.9100 24692.5900
D 1 2.000000 150.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 17 32.500000 2437.5000 0.0000
T 0 0.000000 0.0000 0.0000
181 183.750000 8607.3100 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 342 593.213300 36101.7200 24692.5900
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 516 878.750000 55525.0300 55680.7100
D 4 4.000000 285.7600 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 1 1.000000 71.4400 55.6900
225 596.000000 41378.4700 0.0000
Other 48 79.000000 5925.0000 0.0000
---------------------------------------------------------
Total 794 1558.750000 103185.7000 55736.4000
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 471 375.500000 20050.4000 20050.4000
D 0 0.000000 0.0000 0.0000
S 4 7.500000 535.8000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
889 1632.000000 109453.2500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 1364 2015.000000 130039.4500 20050.4000
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 241 794.000000 53712.9500 53712.9500
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
20 58.500000 3737.0600 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 261 852.500000 57450.0100 53712.9500
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 72 93.250000 6318.4300 3474.7500
D 0 0.000000 0.0000 0.0000
S 16 13.250000 481.0000 0.0000
H 63 78.750000 5314.2300 0.0000
T 659 959.250000 55105.4200 49297.7700
475 759.750000 43909.3100 145.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 1285 1904.250000 111128.3900 52917.5200
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 31 26.630000 1668.4900 2807.0700
D 24 24.000000 1457.2800 0.0000
S 1 0.250000 9.2500 0.0000
H 0 0.000000 0.0000 0.0000
T 26 26.000000 1082.6100 1082.6100
855 878.260000 52518.5800 0.0000
Other 133 134.000000 8319.0000 0.0000
---------------------------------------------------------
Total 1070 1089.140000 65055.2100 3889.6800
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 27 23.830000 1771.6300 1796.2900
D 2 2.000000 142.8800 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 192 196.150000 10275.0200 10275.0200
832 862.620000 54082.2900 0.0000
Other 98 97.500000 6901.0800 0.0000
---------------------------------------------------------
Total 1151 1182.100000 73172.9000 12071.3100
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 715 683.520784 46264.7800 46264.7800
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 3 6.000000 450.0000 0.0000
T 0 0.000000 0.0000 0.0000
828 696.348798 47086.8904 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 1546 1385.869582 93801.6704 46264.7800
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 124 71.750000 4744.7300 4730.8600
D 0 0.000000 0.0000 0.0000
S 9 4.500000 321.4800 321.4800
H 0 0.000000 0.0000 0.0000
T 934 3230.000000 161945.5900 161945.5900
436 609.750000 39717.3400 22321.0800
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 1503 3916.000000 206729.1400 189319.0100