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
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 13289 14480.00000 535658.5000 36.9930
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 8091 7730.250000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 24808 76645.25000 2833710.7500 36.9718
Subtotal (Total Children Is Unduplicated) 26204 98855.50000 3369369.2500 34.0838
-----------------------------------------------------------------------------------------------------------------------
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 54 55.000000 1078.7100 19.6129
AUDE-92553-PURE TONE AUDIOMETRY AIR & BONE 1 1.000000 23.4900 23.4900
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 65 67.000000 988.8500 14.7590
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 68 72.000000 664.5600 9.2300
AUDE-92568-ACOUSTIC REFLEX TESTING (MEMR) 4 4.000000 39.8400 9.9600
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 66 67.000000 1918.5800 28.6355
AUDE-92585-AUD EVOKED RESPONSE (COMP) 2 2.000000 154.2700 77.1350
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 25 25.000000 382.0800 15.2832
AUDE-92588-OTOACOUSTIC EMISSIONS (COMP) 25 26.000000 543.0700 20.8873
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 114 143.500000 7175.0000 50.0000
EXIT-EXIT-EXIT ASSESSMENT 1035 1608.000000 80175.0000 49.8601
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 198 314.000000 23504.9999 74.8567
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 73 118.500532 8887.5400 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 50 78.500000 5691.5000 72.5032
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 138 250.500000 18750.0000 74.8503
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 260 419.000000 23254.5000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 3039 4902.833204 365624.2801 74.5741
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 1212 1920.500006 143048.8804 74.4852
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 930 1430.000000 106857.4500 74.7255
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 3925 6314.000000 349899.0500 55.4164
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 1521 2520.000134 188374.2000 74.7517
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 42 42.000000 4925.1200 117.2648
MED-99204-OUTPATIENT VISIT, NEW, 45 MINS 5 5.000000 1263.8700 252.7740
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 6 6.000000 140.5200 23.4200
MED-99214-OUTPATIENT VISIT, EST, 25 MINS 1 1.000000 36.4900 36.4900
NUTR-97802-NUTRITIONAL EVAL, INITIAL 1 9.000000 450.0000 50.0000
NUTR-97803-NUTRITIONAL EVAL, FOLLOW-UP 5 49.000000 2450.0000 50.0000
OCTF-97168-OT RE-EVAL EST PLAN CARE 27 27.000000 1340.0100 49.6300
OCTH-97165-OT EVAL LOW COMPLEXITY 6 6.000000 243.9700 40.6617
OCTH-97166-OT EVAL MODERATE COMPLEXITY 39 39.000000 1990.9500 51.0500
OCTH-97167-OT EVAL HIGH COMPLEXITY 133 139.000000 6944.9100 49.9634
PSTF-97164-PT RE-EVAL EST PLAN CARE 16 16.000000 699.6200 43.7263
PSTH-97161-PT EVAL LOW COMPLEXITY 5 5.000000 255.2500 51.0500
PSTH-97162-PT EVAL MODERATE COMPLEXITY 39 40.000000 2001.1700 50.0293
PSTH-97163-PT EVAL HIGH COMPLEXITY 126 131.000000 6544.4000 49.9573
SCREEN-T1023-SCREENING 164 179.000000 8950.0000 50.0000
SPCH-92521-EVAL OF SPEECH FLUENCY 3 4.000000 153.1500 38.2875
SPCH-92522-EVAL OF SPCH SOUND PROD 8 8.000000 363.4000 45.4250
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 214 227.000000 11482.0300 50.5816
SPCH-92524-BEHAV & QUAL ANALYSIS OF VOICE AND RES 33 33.000000 1684.6500 51.0500
SPCH-92610-EVAL OF ORAL,PHARYNGEAL SWALLOWING FUNC 15 15.000000 734.1000 48.9400
Subtotal (Total Children Is Unduplicated) 7601 21353.33388 1381467.9604 64.6957
-----------------------------------------------------------------------------------------------------------------------
EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 30 94.000000 16193.7100 172.2735
AUD-92593TS-AUDIOLOGY SERVICES (Biaural) 1 1.000000 50.0000 50.0000
AUDE-V5160-DISPENSING FEE BINAURAL 1 1.000000 59.0000 59.0000
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 1529 1911.750000 94921.4400 49.6516
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 105 83.000000 2075.0000 25.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 1898 2647.000000 132225.0000 49.9528
CONIP-CONIP-CONSULT, ITDS PHONE 213 198.750000 4962.4500 24.9683
CONOF-CONOF-CONSULT, OT, FACE TO FACE 1013 1048.000000 52387.5000 49.9881
CONOP-CONOP-CONSULT, OT, PHONE 75 98.750000 2468.7500 25.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 738 701.250000 35050.0000 49.9822
CONPP-CONPP-CONSULT, PT, PHONE 22 11.750000 293.7500 25.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 1390 1542.250000 77100.0000 49.9919
CONSP-CONSP-CONSULT, SLP, PHONE 161 136.250000 3406.2500 25.0000
COUN-H2019HR-INDIVIDUAL/FAMILY THERAPY 1 2.000000 146.6400 73.3200
DSTT-DSTT-DIRECT SERVICE COORDINATOR TRAVEL 2331 5285.500000 0.0000 0.0000
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 151 3962.250000 99056.2500 25.0000
EIIF-96154-HEALTH AND BEHAVIOR INTERVENTION 2 44.750000 2237.5000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 10537 80623.57000 4027565.4200 49.9552
INTR-T1013-INTERPRETER 454 1377.750000 66831.0000 48.5073
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 14288 117485.0000 1174048.6600 9.9932
OCCT-97530-OT SESSION BY LICENSED OT 1333 6841.150057 477896.2400 69.8561
OCCT-97530HM-OT SESSION BY OT ASST 499 2393.112586 136734.8200 57.1368
PHY-97110-PT SESSION BY LICENSED PT 1381 7570.510078 528428.7100 69.8009
PHY-97110HM-PT SESSION BY PT ASST 229 1127.244932 63927.5300 56.7113
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
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
Eligibility Filter:Program Patients
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
SENS-V5050-IN EAR MONAURAL HEARING AID 1 2.000000 456.0000 228.0000
SENS-V5264-EARMOLD 3 6.000000 108.0000 18.0000
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 2662 16136.63676 1124806.8300 69.7052
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 61 290.750000 16462.3000 56.6201
SPL-92508-GROUP SPL SESSION PER CHILD 52 114.250000 1564.9700 13.6978
TRAV-TRAVS-Travel by mile 6546 571737.0000 251144.8100 0.4393
Subtotal (Total Children Is Unduplicated) 18305 823477.2244 8393361.5300 10.1926
-----------------------------------------------------------------------------------------------------------------------
Total 943686.058286 13144198.7404 13.9286
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 28645
-----------------------------------------------------------------------------------------------------------------------
Center 01
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 211 227.500000 13331.6000 0.0000
P 21809 91013.250000 393529.4300 393345.1100
D 448 1492.000000 11676.2100 0.0000
S 4489 4568.500000 159185.1500 0.0000
H 6418 4625.000000 199951.4000 173847.1300
T 904 2558.250000 18978.7100 18960.2100
6736 4474.000000 153225.2200 0.0000
Other 299 440.000000 28456.5000 0.0000
---------------------------------------------------------
Total 41314 109398.500000 978334.2200 586152.4500
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 5885 16649.500000 142570.2200 142440.8200
213 695.250000 6421.0400 0.0000
Other 6393 20358.500000 137756.8900 0.0000
---------------------------------------------------------
Total 12491 37703.250000 286748.1500 142440.8200
Center 03
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 83 57.000000 2109.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 3491 2450.000000 104438.7500 0.0000
P 2781 27083.750000 68900.9800 68900.9800
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 329 2999.750000 7473.5200 7473.5200
T 835 7246.500000 18192.7500 18192.7500
9550 39253.500000 226177.2300 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 17069 79090.500000 427292.2300 94567.2500
Center 04
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 527 856.750000 31663.7500 37.0000
U 0 0.000000 0.0000 0.0000
B 828 1123.750000 44970.7500 0.0000
P 7831 21371.250000 486965.5400 477032.8800
D 18 21.500000 899.2500 0.0000
S 0 0.000000 0.0000 0.0000
H 3021 11940.500000 608737.3700 260.0000
T 0 0.000000 0.0000 0.0000
5453 7814.250000 282026.9700 0.0000
Other 68 146.500000 9548.0900 30.0000
---------------------------------------------------------
Total 17746 43274.500000 1464811.7200 477359.8800
Center 05
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 15 11.250000 501.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 2396 1571.250000 60631.0000 43378.9900
P 6344 74381.500000 226168.6200 226168.6200
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
3573 7937.000000 68982.2400 15628.2400
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 12328 83901.000000 356282.8600 285175.8500
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 11256 10752.500000 237634.4700 237634.4700
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
24202 19086.500000 758408.2000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 35458 29839.000000 996042.6700 237634.4700
Center 07
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 10 10.750000 397.7500 0.0000
U 0 0.000000 0.0000 0.0000
B 2111 1841.250000 78632.4500 129.5000
P 5382 13550.013300 318255.4000 318227.5800
D 19 18.500000 886.5000 0.0000
S 57 34.000000 1260.0000 0.0000
H 18 34.500000 2587.5000 0.0000
T 0 0.000000 0.0000 0.0000
7281 4526.236700 145373.9100 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 14878 20015.250000 547393.5100 318357.0800
Center 09
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 2 1.500000 55.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 345 377.000000 15821.2500 0.0000
P 23603 183364.250000 1124433.1800 1128214.8600
D 4 4.000000 285.7600 0.0000
S 0 0.000000 0.0000 0.0000
H 413 569.750000 28409.7500 0.0000
T 6 10.000000 600.1900 693.1900
2963 11543.500000 495292.2700 0.0000
Other 281 469.500000 34364.2500 0.0000
---------------------------------------------------------
Total 27617 196339.500000 1699262.1500 1128908.0500
Center 10
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 114 81.750000 3024.7500 0.0000
U 0 0.000000 0.0000 0.0000
B 2859 2195.750000 86692.5000 0.0000
P 18753 38870.250000 1060018.5200 1059833.0500
D 7 8.000000 160.0000 0.0000
S 149 268.250000 10086.8000 80.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
12074 21084.500000 1035879.1900 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 33956 62508.500000 2195861.7600 1059913.0500
Center 51
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 5 5.000000 250.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 265 206.250000 10930.0800 0.0000
P 2197 10211.750000 190260.7800 190260.2800
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
2555 3393.750000 168659.5300 0.0000
Other 1 1.000000 55.5000 0.0000
---------------------------------------------------------
Total 5024 13818.000000 370165.1400 190260.2800
Center 52
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 15 12.750000 743.3900 0.0000
U 0 0.000000 0.0000 0.0000
B 289 301.750000 14234.5800 0.0000
P 1938 2045.250000 95829.5700 92468.9800
D 1 2.000000 150.0000 0.0000
S 144 109.750000 3335.7500 75.0000
H 117 143.500000 9897.8500 0.0000
T 6032 54997.250000 193360.9500 182050.8400
3149 4141.750000 209196.5900 409.2600
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 11685 61754.000000 526748.6800 275004.0800
Center 53
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 10 9.500000 454.8200 0.0000
U 0 0.000000 0.0000 0.0000
B 2523 2373.360000 112793.7300 336.5000
P 1828 1732.630000 79677.2600 80595.1400
D 63 63.250000 3731.3300 0.0000
S 4 2.750000 9.2500 0.0000
H 43 42.750000 3054.0600 0.0000
T 2755 17930.000000 33259.2900 33259.2900
16315 25386.760000 303769.7400 0.0000
Other 180 171.000000 9788.1900 0.0000
---------------------------------------------------------
Total 23721 47712.000000 546537.6700 114190.9300
Center 54
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 110 106.000000 4369.7200 0.0000
U 0 0.000000 0.0000 0.0000
B 3252 2814.250000 134625.1800 145.4400
P 3208 2699.830000 120204.9500 119559.6300
D 108 107.250000 7201.3200 0.0000
S 2 2.000000 10.0000 0.0000
H 38 37.000000 2621.8400 37.0000
T 6455 35566.050000 82224.0500 82224.0500
22449 40876.120000 442179.5400 0.0000
Other 195 175.250000 9883.7100 27.7500
---------------------------------------------------------
Total 35817 82383.750000 803320.3100 201993.8700
Center 55
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 1752 1510.250000 63348.0000 96.2500
P 11152 18868.239438 285623.8101 294097.0400
D 0 0.000000 0.0000 0.0000
S 2 2.666666 200.0000 0.0000
H 9 18.500000 1292.5000 0.0000
T 1 0.750000 27.7500 27.7500
11798 11222.402182 450338.9703 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 24714 31622.808286 800831.0304 294221.0400
Center 57
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 222 266.000000 11344.7500 18.5000
P 3873 4468.000000 181763.4800 178005.8600
D 0 0.000000 0.0000 0.0000
S 183 92.500000 6567.4200 6567.4200
H 0 0.000000 0.0000 0.0000
T 5247 27065.500000 365871.5500 365871.5600
6271 12384.500000 577820.8400 436812.4300
Other 31 49.000000 1198.6000 1198.6000
---------------------------------------------------------
Total 15827 44325.500000 1144566.6400 988474.3700