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:TPIN
Eligibility Filter:Program Patients
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 1 0.750000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 50 107.000000 3885.0000 36.3084
Subtotal (Total Children Is Unduplicated) 50 107.750000 3885.0000 36.0557
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Screening, Eval, and Assessment,Class #02
AUDE-92552-PURE TONE AUDIOMETRY -AIR ONLY 7 7.000000 137.9100 19.7014
AUDE-92553-PURE TONE AUDIOMETRY AIR & BONE 1 1.000000 19.5900 19.5900
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 9 9.000000 132.0300 14.6700
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 9 9.000000 85.2200 9.4689
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 12 12.000000 345.0700 28.7558
AUDE-92585-AUD EVOKED RESPONSE (COMP) 3 3.000000 253.5500 84.5167
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 4 4.000000 58.3800 14.5950
AUDE-92588-OTOACOUSTIC EMISSIONS (COMP) 3 3.000000 62.0700 20.6900
AUDE-V5010-ASSESSMENT FOR HEARING AID 1 1.000000 45.0000 45.0000
AUDE-V5090-DISPENSING FEE PER HEARING AID 1 1.000000 115.0000 115.0000
EVAL-96111-DEVELOPMENTAL EVALUATION 5 9.000000 450.0000 50.0000
EXIT-EXIT-EXIT ASSESSMENT 3 4.500000 225.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 25 40.500000 2947.5000 72.7778
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 8 16.500000 1167.5000 70.7576
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 34 44.000000 3300.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 16 23.000000 1725.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 28 46.000000 2553.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 583 1024.321201 74328.5200 72.5637
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 247 474.050533 34384.7700 72.5340
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 164 269.968133 20212.6100 74.8704
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 699 1224.790000 67192.5000 54.8604
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 308 490.500000 37673.5500 76.8064
OCTH-97165-OT EVAL LOW COMPLEXITY 3 3.000000 153.1500 51.0500
OCTH-97166-OT EVAL MODERATE COMPLEXITY 15 17.000000 765.7500 45.0441
OCTH-97167-OT EVAL HIGH COMPLEXITY 45 45.979432 2296.2000 49.9397
PSTF-97164-PT RE-EVAL EST PLAN CARE 2 2.000000 102.1000 51.0500
PSTH-97162-PT EVAL MODERATE COMPLEXITY 4 4.000000 156.4600 39.1150
PSTH-97163-PT EVAL HIGH COMPLEXITY 16 17.000000 867.8500 51.0500
SCREEN-T1023-SCREENING 17 18.000000 850.0000 47.2222
SPCH-92522-EVAL OF SPCH SOUND PROD 1 1.000000 10.5500 10.5500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 54 59.000000 3011.9500 51.0500
SPCH-92524-BEHAV & QUAL ANALYSIS OF VOICE AND RES 7 7.000000 357.3500 51.0500
Subtotal (Total Children Is Unduplicated) 1311 3891.109299 255985.1300 65.7872
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 12 37.000000 6716.6600 181.5314
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 25 27.000000 1350.0000 50.0000
CONIP-CONIP-CONSULT, ITDS PHONE 10 6.000000 150.0000 25.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 4 5.000000 250.0000 50.0000
CONOP-CONOP-CONSULT, OT, PHONE 5 6.000000 150.0000 25.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 23 23.000000 1150.0000 50.0000
CONSP-CONSP-CONSULT, SLP, PHONE 10 6.500000 162.5000 25.0000
DSTT-DSTT-DIRECT SERVICE COORDINATOR TRAVEL 3 3.000000 0.0000 0.0000
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 1 5.000000 125.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 1136 7305.350000 364408.9400 49.8825
INTR-T1013-INTERPRETER 2 4.500000 225.0000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 1 1.000000 10.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 419 1989.183375 135965.9100 68.3526
OCCT-97530HM-OT SESSION BY OT ASST 119 651.793528 37133.4300 56.9712
PHY-97110-PT SESSION BY LICENSED PT 417 2142.234582 145994.6485 68.1506
PHY-97110HM-PT SESSION BY PT ASST 24 150.305455 8605.7400 57.2550
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 902 4901.620891 332902.8044 67.9169
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 1 0.500000 28.6000 57.2000
SPL-92508-GROUP SPL SESSION PER CHILD 7 18.000000 249.8400 13.8800
TRAV-TRAVS-Travel by mile 1 35.000000 15.5700 0.4449
Subtotal (Total Children Is Unduplicated) 2601 17317.98783 1035594.6429 59.7988
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Total 21316.847130 1295464.7729 60.7719
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Number of Children (Unduplicated) With at Least One Service 3534
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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 2547 2562.500000 136740.0200 136740.0200
D 24 24.000000 1353.2500 0.0000
S 27 28.000000 1473.2300 0.0000
H 334 347.750000 23893.8600 0.0000
T 104 102.500000 6069.3700 6069.3700
231 237.500000 13976.9600 0.0000
Other 9 12.000000 900.0000 0.0000
---------------------------------------------------------
Total 3276 3314.250000 184406.6900 142809.3900
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 438 382.250000 26721.6200 26721.6200
4 3.000000 162.4800 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 442 385.250000 26884.1000 26721.6200
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 70 70.500000 4567.8400 4567.8400
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
41 41.000000 2435.7800 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 111 111.500000 7003.6200 4567.8400
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 105 225.750000 16147.6900 11781.8900
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 27 109.000000 5623.0500 0.0000
T 0 0.000000 0.0000 0.0000
67 66.500000 4948.5000 0.0000
Other 41 84.500000 5631.4800 0.0000
---------------------------------------------------------
Total 240 485.750000 32350.7200 11781.8900
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 117 198.500000 13501.0600 13501.0600
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
16 29.000000 1944.1700 1944.1700
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 133 227.500000 15445.2300 15445.2300
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 645 379.250000 25257.2400 25257.2400
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
1418 1094.000000 75720.1600 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 2063 1473.250000 100977.4000 25257.2400
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 124 335.500000 22807.2800 22807.2800
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 1 2.000000 150.0000 0.0000
T 0 0.000000 0.0000 0.0000
26 16.250000 601.2500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 151 353.750000 23558.5300 22807.2800
Center 09
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 4 4.000000 185.7600 0.0000
P 567 969.750000 61285.9000 62060.6600
D 9 9.000000 642.9600 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
226 558.500000 39138.6000 0.0000
Other 61 98.000000 7320.7500 0.0000
---------------------------------------------------------
Total 867 1639.250000 108573.9700 62060.6600
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 604 438.750000 23637.3300 23623.7500
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
1049 2016.750000 136772.3000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 1653 2455.500000 160409.6300 23623.7500
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 199 635.250000 43010.9300 43010.9300
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
18 38.000000 2498.9400 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 217 673.250000 45509.8700 43010.9300
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 80 112.000000 7689.6000 5090.0100
D 0 0.000000 0.0000 0.0000
S 5 5.000000 185.0000 0.0000
H 86 135.000000 9721.9200 0.0000
T 707 1078.750000 62164.6300 55578.3600
545 857.750000 48702.2500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 1423 2188.500000 128463.4000 60668.3700
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 14 13.750000 940.8700 1754.0300
D 87 105.550000 4415.0500 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 89 89.000000 4427.2500 4427.2500
815 993.000000 61153.5500 0.0000
Other 49 47.750000 2780.3600 0.0000
---------------------------------------------------------
Total 1054 1249.050000 73717.0800 6181.2800
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 14 7.710000 552.5700 934.5700
D 50 48.000000 3406.5600 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 198 201.490000 10832.8876 10832.8800
823 909.850000 56227.6768 0.0000
Other 34 33.000000 2168.4400 0.0000
---------------------------------------------------------
Total 1119 1200.050000 73188.1344 11767.4500
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 559 561.000000 37547.5100 37547.5100
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 13 26.000000 1950.0000 0.0000
T 0 0.000000 0.0000 0.0000
1156 1066.997130 68798.1685 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 1728 1653.997130 108295.6785 37547.5100
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 161 87.500000 6230.6100 6230.6100
D 0 0.000000 0.0000 0.0000
S 35 20.500000 1403.3500 1403.3500
H 0 0.000000 0.0000 0.0000
T 911 3202.000000 160857.3600 160857.3600
478 596.000000 38189.4000 16405.1510
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 1585 3906.000000 206680.7200 184896.4710