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: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 9 6.750000 249.7500 37.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 3 1.750000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 121 249.250000 9213.0000 36.9629
Subtotal (Total Children Is Unduplicated) 124 257.750000 9462.7500 36.7129
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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
EVAL-96111-DEVELOPMENTAL EVALUATION 1 2.000000 100.0000 50.0000
EXIT-EXIT-EXIT ASSESSMENT 5 7.000000 350.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 38 60.825066 4516.8799 74.2602
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 8 16.007866 1200.5900 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 9 14.500000 891.5000 61.4828
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 32 63.500000 4762.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 43 82.000000 4551.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 723 1234.938669 90782.4301 73.5117
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 237 417.554136 30467.9403 72.9676
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 209 326.500000 24142.4500 73.9432
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 721 1247.500000 68901.5500 55.2317
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 335 543.997834 40352.4600 74.1776
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 10 10.000000 3040.0000 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) 1496 4320.638752 286181.5303 66.2359
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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 1075 7394.390000 368870.2900 49.8852
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 395 2144.036953 144958.4400 67.6100
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) 2507 17424.14493 1039539.3000 59.6609
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Total 22002.533680 1335183.5803 60.6832
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Number of Children (Unduplicated) With at Least One Service 3644
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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 2739 2771.750000 146008.3400 146008.3400
D 36 36.000000 1922.4400 0.0000
S 260 274.500000 17223.6900 0.0000
H 348 385.750000 25932.8300 0.0000
T 123 117.000000 6748.7000 6748.7000
124 128.750000 7497.4800 0.0000
Other 22 35.000000 2410.5000 0.0000
---------------------------------------------------------
Total 3652 3748.750000 207743.9800 152757.0400
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 435 379.500000 25620.0900 25619.6300
83 53.500000 3150.1200 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 518 433.000000 28770.2100 25619.6300
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 109 252.500000 16664.3100 11654.3200
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
124 117.500000 11693.0900 0.0000
Other 67 143.500000 9518.0900 0.0000
---------------------------------------------------------
Total 310 557.500000 40097.0900 11654.3200
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
1224 1067.250000 71478.5900 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 2080 1593.000000 106657.6000 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 145 377.763300 25116.9100 24902.5900
D 1 2.000000 150.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 18 34.500000 2587.5000 0.0000
T 0 0.000000 0.0000 0.0000
192 196.000000 9117.5600 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 356 610.263300 36971.9700 24902.5900
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 557 941.250000 59549.9900 59705.6700
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
240 617.500000 42893.4700 0.0000
Other 63 100.000000 7500.0000 0.0000
---------------------------------------------------------
Total 865 1663.750000 110300.6600 59761.3600
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
979 1807.000000 121320.5000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 1454 2190.000000 141906.7000 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 81 110.250000 7525.1800 4126.5600
D 1 2.000000 150.0000 0.0000
S 16 13.250000 481.0000 0.0000
H 79 108.250000 7399.9800 0.0000
T 682 1003.250000 57577.3400 51639.6900
493 795.750000 46139.2900 145.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 1352 2032.750000 119272.7900 55911.2500
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 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
895 931.760000 55775.5200 0.0000
Other 133 134.000000 8319.0000 0.0000
---------------------------------------------------------
Total 1110 1142.640000 68312.1500 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 201 212.650000 11268.7700 11268.7700
860 910.820000 57397.5400 0.0000
Other 99 99.500000 7012.0800 0.0000
---------------------------------------------------------
Total 1189 1248.800000 77592.9000 13065.0600
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 725 703.520784 47764.7800 47764.7800
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 8 16.000000 1200.0000 0.0000
T 0 0.000000 0.0000 0.0000
857 735.059596 49901.2003 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 1590 1454.580380 98865.9803 47764.7800
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 939 3241.000000 162656.5900 162656.5900
500 678.750000 44219.5900 22321.0800
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 1572 3996.000000 211942.3900 190030.0100