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: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 13284 14473.25000 535408.7500 36.9930
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 7945 7642.000000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 8780 26784.50000 990323.5000 36.9738
Subtotal (Total Children Is Unduplicated) 20037 48899.75000 1525732.2500 31.2012
-----------------------------------------------------------------------------------------------------------------------
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 114 141.500000 7075.0000 50.0000
EXIT-EXIT-EXIT ASSESSMENT 1021 1583.500000 78950.0000 49.8579
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 37 54.674934 4100.6200 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 15 19.992666 1499.4500 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 8 12.000000 900.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 23 38.500000 2887.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 63 90.500000 5022.7500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 554 887.927869 66381.8500 74.7604
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 234 344.945870 25870.9401 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 194 299.500000 22462.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 877 1273.500000 70651.5000 55.4782
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 338 523.556167 39125.7800 74.7308
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 26 26.000000 1531.6600 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 99 112.000000 5600.0000 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) 2808 5867.782325 348059.5601 59.3171
-----------------------------------------------------------------------------------------------------------------------
EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 26 58.000000 12442.5900 214.5274
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 1523 1899.250000 94296.4400 49.6493
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 101 79.000000 1975.0000 25.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 1897 2643.000000 132025.0000 49.9527
CONIP-CONIP-CONSULT, ITDS PHONE 211 196.750000 4912.4500 24.9680
CONOF-CONOF-CONSULT, OT, FACE TO FACE 1008 1040.000000 51987.5000 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 1383 1533.250000 76650.0000 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 2331 5282.000000 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 3226 22458.32000 1120279.7700 49.8826
INTR-T1013-INTERPRETER 454 1374.750000 66681.0000 48.5041
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 14287 117448.0000 1173678.6600 9.9932
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 6335 520133.0000 228546.4800 0.4394
Subtotal (Total Children Is Unduplicated) 17498 685124.3754 3688445.4900 5.3836
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:Program Patients
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
-----------------------------------------------------------------------------------------------------------------------
Total 739891.907692 5562237.3001 7.5176
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 25749
-----------------------------------------------------------------------------------------------------------------------
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 19066 88238.500000 247410.0900 247225.7700
D 287 1328.500000 3514.7100 0.0000
S 548 1471.000000 13068.7800 0.0000
H 2 3.000000 171.4400 0.0000
T 780 2440.750000 12211.5100 12211.5100
6583 4331.000000 145166.0500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 27266 97812.750000 421542.5800 259437.2800
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 5450 16270.000000 116950.1300 116821.1900
130 641.750000 3270.9200 0.0000
Other 4276 18868.000000 71222.8900 0.0000
---------------------------------------------------------
Total 9856 35779.750000 191443.9400 116821.1900
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
9406 39124.000000 219601.6500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 13253 76358.000000 309112.0900 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
4806 4327.750000 172306.2600 0.0000
Other 1 3.000000 30.0000 30.0000
---------------------------------------------------------
Total 8919 20275.500000 437222.1500 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 6225 74130.500000 208635.0200 208635.0200
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
3557 7921.500000 68292.0800 15271.0800
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 9783 82052.250000 276936.3500 223906.1000
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 10397 10223.750000 202344.4600 202344.4600
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
11796 8306.500000 216854.7700 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 22193 18530.250000 419199.2300 202344.4600
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 3783 11754.250000 232212.2400 232239.9900
D 17 16.250000 727.2500 0.0000
S 53 28.500000 943.5000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
6913 4199.486700 131235.6000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 10766 15998.486700 365118.5900 232239.9900
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 16111 123066.000000 669325.2900 669325.2900
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 16338 126211.750000 683655.7900 669325.2900
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
6731 5338.250000 177948.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 18383 38210.500000 973578.8700 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 1611 9161.250000 125679.5800 125679.5800
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
1415 1063.750000 36440.7500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 3027 10225.250000 162129.5800 125679.5800
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 123 92.000000 2599.2500 0.0000
H 0 0.000000 0.0000 0.0000
T 5349 53992.000000 135755.0500 130382.5900
1604 1162.250000 31905.7600 264.2600
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 7079 55276.500000 170295.4600 130682.2500
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 3 2.500000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 2729 17904.000000 32176.6800 32176.6800
14289 23257.250000 182288.2500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 17031 41173.250000 214783.1800 32272.9300
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 6254 35353.400000 70955.2800 70955.2800
19007 37277.250000 245202.4100 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 25275 72642.150000 316670.3400 70983.0300
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 7514 15706.968654 138176.7801 138176.7800
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 1 2.500000 92.5000 0.0000
T 0 0.000000 0.0000 0.0000
7043 6432.052338 153194.4100 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 14559 22141.770992 291472.9401 138176.7800
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 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 4307 23823.500000 203163.9100 203163.9200
3393 3292.250000 119666.3600 387.8600
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 7874 27203.750000 329076.2100 209797.7200