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
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 13030 14395.00000 532421.2500 36.9865
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 7363 6917.000000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 8627 25805.50000 954180.0000 36.9758
Subtotal (Total Children Is Unduplicated) 19631 47117.50000 1486601.2500 31.5509
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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 83 90.000000 1764.3000 19.6033
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 90 98.000000 1426.4600 14.5557
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 85 93.000000 875.6400 9.4155
AUDE-92568-ACOUSTIC REFLEX TESTING (MEMR) 1 1.000000 9.9600 9.9600
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 92 100.000000 2867.8400 28.6784
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 29 29.000000 437.0500 15.0707
AUDE-92588-OTOACOUSTIC EMISSIONS (COMP) 40 44.000000 913.7800 20.7677
AUDE-V5010-ASSESSMENT FOR HEARING AID 1 2.000000 90.0000 45.0000
AUDE-V5090-DISPENSING FEE PER HEARING AID 1 2.000000 75.0000 37.5000
EVAL-96111-DEVELOPMENTAL EVALUATION 83 101.750000 5098.5000 50.1081
EXIT-EXIT-EXIT ASSESSMENT 906 1385.500000 68975.0000 49.7835
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 44 65.500000 4912.5000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 18 22.500000 1687.5000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 25 40.000000 3000.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 24 33.500000 2512.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 91 124.000000 6882.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 581 933.705200 69746.6000 74.6987
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 243 364.240933 27318.0700 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 210 334.869467 25115.2100 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 937 1359.000000 75375.9400 55.4643
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 332 523.003466 39168.6300 74.8917
NUTR-97802-NUTRITIONAL EVAL, INITIAL 1 1.000000 50.0000 50.0000
NUTR-97803-NUTRITIONAL EVAL, FOLLOW-UP 4 30.000000 1500.0000 50.0000
OCTF-97168-OT RE-EVAL EST PLAN CARE 2 2.000000 102.1000 51.0500
OCTH-97166-OT EVAL MODERATE COMPLEXITY 15 15.000000 725.1500 48.3433
OCTH-97167-OT EVAL HIGH COMPLEXITY 55 54.020568 2675.8900 49.5347
PSTF-97164-PT RE-EVAL EST PLAN CARE 3 3.000000 153.1500 51.0500
PSTH-97161-PT EVAL LOW COMPLEXITY 6 6.000000 306.3000 51.0500
PSTH-97162-PT EVAL MODERATE COMPLEXITY 4 4.000000 204.2000 51.0500
PSTH-97163-PT EVAL HIGH COMPLEXITY 13 13.000000 663.6500 51.0500
SCREEN-T1023-SCREENING 57 68.000000 3400.0000 50.0000
SPCH-92521-EVAL OF SPEECH FLUENCY 1 1.000000 51.0500 51.0500
SPCH-92522-EVAL OF SPCH SOUND PROD 5 5.000000 255.2500 51.0500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 64 64.000000 3267.2000 51.0500
SPCH-92524-BEHAV & QUAL ANALYSIS OF VOICE AND RES 8 8.000000 408.4000 51.0500
Subtotal (Total Children Is Unduplicated) 2764 6046.589634 353275.8200 58.4256
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 38 111.000000 13060.2200 117.6596
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 1489 1817.750000 90401.3300 49.7325
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 102 85.250000 2112.5000 24.7801
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 1697 2535.250000 126428.7500 49.8684
CONIP-CONIP-CONSULT, ITDS PHONE 248 252.500000 6300.0000 24.9505
CONOF-CONOF-CONSULT, OT, FACE TO FACE 896 874.250000 43712.5000 50.0000
CONOP-CONOP-CONSULT, OT, PHONE 140 171.000000 4256.2500 24.8904
CONPF-CONPF-CONSULT, PT, FACE TO FACE 668 644.000000 30700.0000 47.6708
CONPP-CONPP-CONSULT, PT, PHONE 28 18.250000 456.2500 25.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 1278 1392.000000 69600.0000 50.0000
CONSP-CONSP-CONSULT, SLP, PHONE 155 145.750000 3618.7500 24.8285
DSTT-DSTT-DIRECT SERVICE COORDINATOR TRAVEL 2195 4933.000000 0.0000 0.0000
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 30 114.500000 2862.5000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 3184 21575.15000 1076478.3100 49.8944
INTR-T1013-INTERPRETER 534 1302.500000 63294.2500 48.5944
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 14238 114712.0000 1146507.0800 9.9947
OCCT-97530-OT SESSION BY LICENSED OT 410 1836.525608 128013.5300 69.7042
OCCT-97530HM-OT SESSION BY OT ASST 82 388.832344 22241.2100 57.2000
PHY-97110-PT SESSION BY LICENSED PT 439 2159.475502 149915.6300 69.4222
PHY-97110HM-PT SESSION BY PT ASST 19 101.194542 5764.0000 56.9596
SENS-V5264-EARMOLD 2 4.000000 72.0000 18.0000
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 964 5115.484601 356071.2200 69.6065
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 1 2.500000 143.0000 57.2000
SPL-92508-GROUP SPL SESSION PER CHILD 4 11.000000 152.6800 13.8800
TRAV-TRAVS-Travel by mile 6299 510455.0000 224604.3800 0.4400
Subtotal (Total Children Is Unduplicated) 17411 670761.1626 3567276.3400 5.3183
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Total 723925.252231 5407153.4100 7.4692
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Number of Children (Unduplicated) With at Least One Service 25472
-----------------------------------------------------------------------------------------------------------------------
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 18784 88861.750000 239432.0900 239432.0900
D 138 729.500000 1879.6500 0.0000
S 271 1695.250000 5230.1300 0.0000
H 0 0.000000 0.0000 0.0000
T 361 1104.750000 6309.6400 6309.6400
6884 4706.750000 166203.3100 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 26438 97098.000000 419054.8200 245741.7300
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 4598 14478.750000 93219.2700 93183.1200
37 33.500000 568.6000 0.0000
Other 3942 16696.000000 68017.6400 0.0000
---------------------------------------------------------
Total 8577 31208.250000 161805.5100 93183.1200
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 3731 38174.500000 87975.2100 87975.2100
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
8061 29028.500000 195184.7200 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 11999 68661.500000 286706.2400 91521.5200
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 3856 14266.000000 242281.9100 242281.9100
D 1 1.500000 55.5000 0.0000
S 0 0.000000 0.0000 0.0000
H 10 29.000000 290.0000 290.0000
T 0 0.000000 0.0000 0.0000
3990 3549.500000 142024.7500 0.0000
Other 4 16.000000 480.0000 480.0000
---------------------------------------------------------
Total 7861 17862.000000 385132.1600 243051.9100
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 6520 70605.250000 214517.4900 214517.4900
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
3889 9762.000000 76367.0100 21097.2600
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 10409 80367.250000 290884.5000 235614.7500
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 9909 9795.250000 198967.8500 198967.8500
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
12298 9266.000000 231155.1000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 22207 19061.250000 430122.9500 198967.8500
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 3240 10130.000000 185663.8000 185607.2600
D 31 28.500000 1091.5000 0.0000
S 0 0.000000 0.0000 0.0000
H 52 104.000000 7800.0000 0.0000
T 0 0.000000 0.0000 0.0000
7459 4438.750000 133291.0000 0.0000
Other 1 2.000000 111.0000 0.0000
---------------------------------------------------------
Total 10783 14703.250000 327957.3000 185607.2600
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 15394 114321.500000 648460.3200 648460.3200
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
300 5738.500000 19886.6000 0.0000
Other 9 14.000000 1050.0000 0.0000
---------------------------------------------------------
Total 15703 120074.000000 669396.9200 648460.3200
Center 10
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 1 0.500000 18.5000 0.0000
P 10268 31762.000000 762741.4000 762741.4000
D 41 40.750000 1089.5900 0.0000
S 107 212.000000 4570.3000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
6224 5026.500000 167233.2500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 16641 37041.750000 935653.0400 762741.4000
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 1473 7332.500000 109998.7000 109998.7000
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
2951 1886.250000 63725.4000 30.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 4424 9218.750000 173724.1000 110028.7000
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 2 50.000000 93.2400 93.2400
D 0 0.000000 0.0000 0.0000
S 69 58.250000 2072.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 5469 56292.500000 136911.1300 131785.9810
1972 1372.750000 39962.3000 106.6700
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 7512 57773.500000 179038.6700 131985.8910
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 1 0.250000 9.2500 9.2500
D 22 28.500000 1332.5000 0.0000
S 1 1.000000 37.0000 0.0000
H 1 1.000000 71.4400 0.0000
T 3815 28827.250000 46615.2800 46615.2800
12430 17892.500000 160005.1400 37.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 16270 46750.500000 208070.6100 46661.5300
Center 54
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 2 1.250000 46.2500 0.0000
P 0 0.000000 0.0000 0.0000
D 39 36.750000 2520.6100 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 6579 39112.500000 78423.1000 78423.1000
17728 36858.250000 224009.9000 46.2500
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 24348 76008.750000 304999.8600 78469.3500
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 0.0000 0.0000
P 7657 13838.073666 135169.5500 135169.5500
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
6987 6191.428565 147354.0800 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 14645 20029.752231 282523.6300 135169.5500
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 72 37.500000 2617.8300 2617.8300
H 0 0.000000 0.0000 0.0000
T 4656 24259.500000 213147.2700 213057.3300
3590 3762.750000 136248.0000 130.0000
Other 1 7.000000 70.0000 70.0000
---------------------------------------------------------
Total 8319 28066.750000 352083.1000 215875.1600