CMS/EIP Fiscal Report Statewide
Services beginning 10/01/2019 ending 12/31/2019 Date of Report:02/01/2020 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 13030 14395.00000 532421.2500 36.9865
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 7502 7009.250000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 24285 74348.75000 2749097.2500 36.9757
Subtotal (Total Children Is Unduplicated) 25868 95753.00000 3281518.5000 34.2707
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Screening, Eval, and Assessment,Class #02
ASTE-ASTE-ASSISTIVE TECHNOLOGY EVAL 23 26.000000 1261.0000 48.5000
AUDE-92552-PURE TONE AUDIOMETRY -AIR ONLY 90 97.000000 1902.2100 19.6104
AUDE-92553-PURE TONE AUDIOMETRY AIR & BONE 1 1.000000 19.5900 19.5900
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 99 107.000000 1558.4900 14.5653
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 94 102.000000 960.8600 9.4202
AUDE-92568-ACOUSTIC REFLEX TESTING (MEMR) 1 1.000000 9.9600 9.9600
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 104 112.000000 3212.9100 28.6867
AUDE-92585-AUD EVOKED RESPONSE (COMP) 3 3.000000 253.5500 84.5167
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 33 33.000000 495.4300 15.0130
AUDE-92588-OTOACOUSTIC EMISSIONS (COMP) 43 47.000000 975.8500 20.7628
AUDE-V5010-ASSESSMENT FOR HEARING AID 2 3.000000 135.0000 45.0000
AUDE-V5090-DISPENSING FEE PER HEARING AID 2 3.000000 190.0000 63.3333
EVAL-96111-DEVELOPMENTAL EVALUATION 84 110.750000 5548.5000 50.0993
EXIT-EXIT-EXIT ASSESSMENT 918 1408.250000 70112.5000 49.7870
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 181 278.000000 20760.0000 74.6763
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 98 146.000000 10842.5000 74.2637
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 104 148.000000 11100.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 126 213.500000 16012.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 286 435.500000 24170.2500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 2783 4587.526401 341268.1200 74.3904
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 1368 2226.163199 165763.9700 74.4617
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 918 1468.837600 110049.8200 74.9231
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 3956 6374.790000 352885.6900 55.3564
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 1530 2511.306933 189102.4400 75.3004
NUTR-97802-NUTRITIONAL EVAL, INITIAL 2 4.000000 200.0000 50.0000
NUTR-97803-NUTRITIONAL EVAL, FOLLOW-UP 5 52.000000 2600.0000 50.0000
OCTF-97168-OT RE-EVAL EST PLAN CARE 7 7.000000 357.3500 51.0500
OCTH-97165-OT EVAL LOW COMPLEXITY 7 7.000000 357.3500 51.0500
OCTH-97166-OT EVAL MODERATE COMPLEXITY 40 43.000000 2052.4500 47.7314
OCTH-97167-OT EVAL HIGH COMPLEXITY 169 171.000000 8596.6400 50.2727
PSTF-97164-PT RE-EVAL EST PLAN CARE 8 8.000000 408.4000 51.0500
PSTH-97161-PT EVAL LOW COMPLEXITY 8 8.000000 408.4000 51.0500
PSTH-97162-PT EVAL MODERATE COMPLEXITY 20 20.000000 973.2600 48.6630
PSTH-97163-PT EVAL HIGH COMPLEXITY 61 63.000000 3216.1500 51.0500
SCREEN-T1023-SCREENING 147 167.000000 8300.0000 49.7006
SPCH-92521-EVAL OF SPEECH FLUENCY 2 2.000000 102.1000 51.0500
SPCH-92522-EVAL OF SPCH SOUND PROD 6 6.000000 265.8000 44.3000
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 153 161.000000 8219.0500 51.0500
SPCH-92524-BEHAV & QUAL ANALYSIS OF VOICE AND RES 20 20.000000 1021.0000 51.0500
SPCH-92610-EVAL OF ORAL,PHARYNGEAL SWALLOWING FUNC 1 1.000000 48.9400 48.9400
Subtotal (Total Children Is Unduplicated) 7328 21183.62413 1365718.0300 64.4705
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 49 179.000000 22791.3400 127.3259
AUD-92593TS-AUDIOLOGY SERVICES (Biaural) 1 1.000000 50.0000 50.0000
AUDE-V5160-DISPENSING FEE BINAURAL 1 2.000000 460.0000 230.0000
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 1499 1832.500000 91138.8300 49.7347
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 105 88.250000 2187.5000 24.7875
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 1724 2568.250000 128078.7500 49.8700
CONIP-CONIP-CONSULT, ITDS PHONE 250 258.500000 6450.0000 24.9516
CONOF-CONOF-CONSULT, OT, FACE TO FACE 899 881.250000 44062.5000 50.0000
CONOP-CONOP-CONSULT, OT, PHONE 142 177.000000 4406.2500 24.8941
CONPF-CONPF-CONSULT, PT, FACE TO FACE 669 645.000000 30750.0000 47.6744
CONPP-CONPP-CONSULT, PT, PHONE 28 18.250000 456.2500 25.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 1310 1426.000000 71300.0000 50.0000
CONSP-CONSP-CONSULT, SLP, PHONE 157 152.250000 3781.2500 24.8358
DSTT-DSTT-DIRECT SERVICE COORDINATOR TRAVEL 2196 4936.000000 0.0000 0.0000
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 78 1104.250000 27606.2500 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 10584 79370.25000 3965042.2600 49.9563
INTR-T1013-INTERPRETER 535 1307.000000 63519.2500 48.5993
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 14242 114817.0000 1147557.0800 9.9947
OCCT-97530-OT SESSION BY LICENSED OT 1368 6773.636195 474391.6200 70.0350
OCCT-97530HM-OT SESSION BY OT ASST 437 2295.625872 131160.6000 57.1350
PHY-97110-PT SESSION BY LICENSED PT 1407 7635.960084 533848.3185 69.9124
PHY-97110HM-PT SESSION BY PT ASST 144 784.125259 44814.6000 57.1523
SENS-V5264-EARMOLD 2 4.000000 72.0000 18.0000
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 2629 16402.85549 1144093.5544 69.7497
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 3 5.000000 286.0000 57.2000
SPL-92508-GROUP SPL SESSION PER CHILD 26 68.750000 954.2500 13.8800
TRAV-TRAVS-Travel by mile 6567 560307.0000 246301.3600 0.4396
Subtotal (Total Children Is Unduplicated) 18239 804040.7029 8185559.8129 10.1805
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Total 920977.327035 12832796.3429 13.9339
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Number of Children (Unduplicated) With at Least One Service 28221
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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 202 201.250000 14319.3000 0.0000
P 21333 91426.250000 376272.1100 376272.1100
D 255 848.000000 8021.0000 0.0000
S 2829 3652.250000 91478.2300 0.0000
H 7132 5314.500000 232411.4800 208392.6000
T 465 1207.250000 12379.0100 12379.0100
7128 4951.000000 180464.4600 0.0000
Other 348 556.000000 35606.2500 0.0000
---------------------------------------------------------
Total 39692 108156.500000 950951.8400 597043.7200
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 5036 14861.000000 119940.8900 119904.7400
41 36.500000 731.0800 0.0000
Other 5716 17919.750000 122992.3900 0.0000
---------------------------------------------------------
Total 10793 32817.250000 243664.3600 119904.7400
Center 03
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 43 32.000000 1221.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 3212 2452.750000 104620.8400 0.0000
P 3801 38245.000000 92543.0500 92543.0500
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 207 1458.500000 3546.3100 3546.3100
T 0 0.000000 0.0000 0.0000
8148 29129.000000 201468.2300 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 15411 71317.250000 403399.4300 96089.3600
Center 04
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 516 792.250000 29313.2500 0.0000
U 0 0.000000 0.0000 0.0000
B 1109 1654.250000 65618.0000 46.2500
P 7006 19138.000000 442521.0000 433617.7400
D 1 1.500000 55.5000 0.0000
S 0 0.000000 0.0000 0.0000
H 2757 10492.500000 533615.2100 290.0000
T 0 0.000000 0.0000 0.0000
4277 3834.500000 160622.0000 0.0000
Other 45 100.500000 6111.4800 480.0000
---------------------------------------------------------
Total 15711 36013.500000 1237856.4400 434433.9900
Center 05
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 2610 1773.500000 69898.1700 42287.0000
P 6637 70803.750000 228018.5500 228018.5500
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
3907 9791.500000 78329.6800 23041.4300
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 13154 82368.750000 376246.4000 293346.9800
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 10554 10174.500000 224225.0900 224225.0900
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
24973 20169.500000 786535.2500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 35527 30344.000000 1010760.3400 224225.0900
Center 07
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 120 133.500000 4952.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 620 536.250000 21968.5000 0.0000
P 6375 13214.500000 328280.0800 328250.9900
D 31 28.500000 1091.5000 0.0000
S 0 0.000000 0.0000 0.0000
H 53 106.000000 7950.0000 0.0000
T 0 0.000000 0.0000 0.0000
7599 4540.500000 137168.7500 0.0000
Other 1 2.000000 111.0000 0.0000
---------------------------------------------------------
Total 14799 18561.250000 501522.3300 328250.9900
Center 09
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 2 0.500000 18.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 182 191.250000 7686.7600 120.2500
P 22607 172407.750000 1081152.6400 1081927.4000
D 15 14.500000 922.4600 0.0000
S 0 0.000000 0.0000 0.0000
H 577 804.000000 39782.2500 0.0000
T 3 4.500000 240.5000 425.5000
2950 13882.500000 486376.2800 0.0000
Other 267 450.000000 32872.5000 0.0000
---------------------------------------------------------
Total 26603 187755.000000 1649051.8900 1082473.1500
Center 10
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 189 163.750000 6058.7500 0.0000
U 0 0.000000 0.0000 0.0000
B 3618 2975.000000 122719.5000 18.5000
P 17052 37304.750000 1005208.0300 1004001.1080
D 49 50.500000 1450.3400 0.0000
S 141 298.000000 8870.3000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
11849 21284.250000 1072704.3000 0.0000
Other 1 0.500000 18.5000 0.0000
---------------------------------------------------------
Total 32899 62076.750000 2217029.7200 1004019.6080
Center 51
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 5 5.000000 277.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 636 422.000000 16791.2500 0.0000
P 1714 8010.750000 155258.6300 155389.1300
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
4689 4572.750000 211355.8300 30.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 7044 13010.500000 383683.2100 155419.1300
Center 52
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 13 12.500000 547.0000 18.5000
U 0 0.000000 0.0000 0.0000
B 312 303.500000 14945.7300 0.0000
P 1890 1952.500000 89657.7900 86842.1000
D 0 0.000000 0.0000 0.0000
S 315 272.500000 10097.7500 0.0000
H 125 172.750000 12245.5000 74.9000
T 6177 57371.500000 199085.0100 187364.3410
3716 4601.500000 232450.5100 106.6700
Other 1 0.250000 9.2500 9.2500
---------------------------------------------------------
Total 12549 64687.000000 559038.5400 274415.7610
Center 53
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 37 30.500000 1294.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 1789 1688.500000 79867.0000 50.0000
P 1717 1665.250000 79448.2200 80120.9600
D 197 214.800000 11327.1700 0.0000
S 1 1.000000 37.0000 0.0000
H 29 30.250000 2102.3700 0.0000
T 3904 28916.250000 51042.5300 51042.5300
14677 20371.250000 298021.7700 37.0000
Other 78 74.750000 4574.1900 0.0000
---------------------------------------------------------
Total 22429 52992.550000 527714.7500 131250.4900
Center 54
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 136 144.750000 5649.6400 0.0000
U 0 0.000000 0.0000 0.0000
B 2694 2149.250000 99045.9400 55.5000
P 3340 2681.710000 118939.0000 5049049.7400
D 176 170.500000 11346.6800 0.0000
S 0 0.000000 0.0000 0.0000
H 23 23.750000 1700.5500 0.0000
T 6777 39313.990000 89255.9876 89255.9800
21523 40848.350000 440799.2968 46.2500
Other 84 85.250000 5874.7300 64.7500
---------------------------------------------------------
Total 34753 85417.550000 772611.8244 5138472.2200
Center 55
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 1026 863.500000 36804.5000 0.0000
P 11300 17114.823666 285139.5600 284870.0600
D 0 0.000000 0.0000 0.0000
S 1 1.303467 97.7600 0.0000
H 13 26.000000 1950.0000 0.0000
T 0 0.000000 0.0000 0.0000
13353 12725.099902 546800.6785 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 25693 30730.727035 870792.4985 284870.0600
Center 57
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 1 1.000000 37.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 379 458.250000 17763.7500 55.0000
P 3732 4288.250000 176202.8600 172829.6300
D 0 0.000000 0.0000 0.0000
S 107 58.000000 4021.1800 4021.1800
H 12 14.500000 1087.5000 0.0000
T 5571 27479.000000 374522.5100 374432.5700
6127 12273.750000 551079.7400 392623.3210
Other 102 156.000000 3758.2300 3758.2300
---------------------------------------------------------
Total 16031 44728.750000 1128472.7700 947719.9310