CMS/EIP Fiscal Report Statewide
Services beginning 01/01/2020 ending 03/31/2020 Date of Report:05/15/2020 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 13756 15938.25000 589558.0000 36.9901
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 7084 6706.500000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 24957 80226.25000 2966692.2500 36.9791
Subtotal (Total Children Is Unduplicated) 26302 102871.0000 3556250.2500 34.5700
-----------------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
ASTE-ASTE-ASSISTIVE TECHNOLOGY EVAL 25 28.000000 1358.0000 48.5000
AUDE-92552-PURE TONE AUDIOMETRY -AIR ONLY 59 64.000000 1217.3400 19.0209
AUDE-92553-PURE TONE AUDIOMETRY AIR & BONE 3 3.000000 70.7500 23.5833
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 73 79.000000 1107.9900 14.0252
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 57 60.000000 555.8700 9.2645
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 73 80.000000 2221.2400 27.7655
AUDE-92582-CONDITIONED PLAY AUDIOMETRY 1 1.000000 38.4700 38.4700
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 21 22.000000 352.8600 16.0391
AUDE-92588-OTOACOUSTIC EMISSIONS (COMP) 21 22.000000 472.2800 21.4673
AUDE-V5010-ASSESSMENT FOR HEARING AID 2 2.000000 90.0000 45.0000
AUDE-V5090-DISPENSING FEE PER HEARING AID 1 2.000000 230.0000 115.0000
EVAL-96111-DEVELOPMENTAL EVALUATION 55 72.750000 3637.5000 50.0000
EXIT-EXIT-EXIT ASSESSMENT 941 1456.750000 72837.5000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 189 296.500000 22155.4000 74.7231
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 2 3.000000 225.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 81 118.500000 8850.0000 74.6835
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 3 4.500000 337.5000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 46 75.000000 5625.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 117 201.000000 15928.4600 79.2461
IPDEF-T1024TLTSGT-F/U PHYC AND DEV EVAL BY EI PROF 3 6.000000 450.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 268 442.000000 24531.0000 55.5000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 7 8.500000 471.7500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 2673 4440.423196 331547.2399 74.6657
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 37 54.336800 4075.2600 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 1245 2010.236532 150102.6400 74.6691
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 34 50.000000 3750.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 804 1296.161867 96765.4900 74.6554
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 10 15.000000 1125.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 3356 5457.500000 302350.0000 55.4008
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 60 105.000000 5716.5000 54.4429
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 1207 1962.342400 151976.9700 77.4467
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 18 33.000000 2475.0000 75.0000
NUTR-97802-NUTRITIONAL EVAL, INITIAL 2 9.000000 450.0000 50.0000
NUTR-97803-NUTRITIONAL EVAL, FOLLOW-UP 16 63.000000 3150.0000 50.0000
OCTF-97168-OT RE-EVAL EST PLAN CARE 10 10.000000 510.5000 51.0500
OCTH-97165-OT EVAL LOW COMPLEXITY 11 11.000000 561.5500 51.0500
OCTH-97165GT-OT EVAL LOW COMPLEXITY 1 1.000000 51.0500 51.0500
OCTH-97166-OT EVAL MODERATE COMPLEXITY 33 34.000000 1615.2300 47.5068
OCTH-97167-OT EVAL HIGH COMPLEXITY 178 181.000000 9042.9600 49.9611
OCTH-97167GT-OT EVAL HIGH COMPLEXITY 1 1.000000 51.0500 51.0500
PSTF-97164-PT RE-EVAL EST PLAN CARE 5 5.000000 255.2500 51.0500
PSTH-97161-PT EVAL LOW COMPLEXITY 2 2.000000 102.1000 51.0500
PSTH-97162-PT EVAL MODERATE COMPLEXITY 31 31.000000 1582.5500 51.0500
PSTH-97163-PT EVAL HIGH COMPLEXITY 56 58.000000 2948.9000 50.8431
SCREEN-T1023-SCREENING 174 285.000000 14300.0000 50.1754
SPCH-92521-EVAL OF SPEECH FLUENCY 7 7.000000 357.3500 51.0500
SPCH-92522-EVAL OF SPCH SOUND PROD 4 4.000000 204.2000 51.0500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 190 195.000000 9776.0600 50.1336
SPCH-92523GT-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 2 2.000000 102.1000 51.0500
SPCH-92524-BEHAV & QUAL ANALYSIS OF VOICE AND RES 37 37.000000 1888.8500 51.0500
SPCH-92610-EVAL OF ORAL,PHARYNGEAL SWALLOWING FUNC 11 14.000000 539.8300 38.5593
Subtotal (Total Children Is Unduplicated) 6716 19421.50080 1260137.5399 64.8836
-----------------------------------------------------------------------------------------------------------------------
EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 20 34.000000 9719.6400 285.8718
AUD-92593TS-AUDIOLOGY SERVICES (Biaural) 1 1.000000 50.0000 50.0000
AUDE-V5160-DISPENSING FEE BINAURAL 1 1.000000 230.0000 230.0000
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 1570 1932.500000 96397.5000 49.8823
COIFF-COIFFGT-IFSP CONSULT,PROF,FACE TO FACE 41 54.500000 2725.0000 50.0000
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 205 202.000000 5050.0000 25.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 1936 2704.750000 135200.0000 49.9861
CONIF-CONIFGT-CONSULT,ITDS,FACE TO FACE 188 122.750000 6100.0000 49.6945
CONIP-CONIP-CONSULT, ITDS PHONE 270 271.000000 6775.0000 25.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 1106 1085.750000 54287.5000 50.0000
CONOF-CONOFGT-CONSULT,OT,FACE TO FACE 42 31.000000 1550.0000 50.0000
CONOP-CONOP-CONSULT, OT, PHONE 113 195.250000 4875.0000 24.9680
CONPF-CONPF-CONSULT, PT, FACE TO FACE 639 568.000000 28400.0000 50.0000
CONPF-CONPFGT-CONSULT,PT,FACE TO FACE 27 16.500000 825.0000 50.0000
CONPP-CONPP-CONSULT, PT, PHONE 43 17.000000 425.0000 25.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 1413 1505.500000 75087.5000 49.8755
CONSF-CONSFGT-CONSULT,SLP,FACE TO FACE 50 40.500000 2025.0000 50.0000
CONSP-CONSP-CONSULT, SLP, PHONE 161 127.250000 3181.2500 25.0000
DSTT-DSTT-DIRECT SERVICE COORDINATOR TRAVEL 1982 4383.000000 0.0000 0.0000
CMS/EIP Fiscal Report Statewide
Services beginning 01/01/2020 ending 03/31/2020 Date of Report:05/15/2020 Page: 2
List order: No List
Eligibility Filter:Program Patients
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 70 778.000000 19450.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 10620 76435.50000 3808342.5000 49.8243
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 1738 2596.250000 129812.5000 50.0000
INTR-T1013-INTERPRETER 508 1389.910000 69378.7400 49.9160
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 14371 112185.0000 1121043.5800 9.9928
OCCT-97530-OT SESSION BY LICENSED OT 1447 7301.435890 512103.3700 70.1374
OCCT-97530GT-OT SESSION BY LICENSED OT 189 255.250000 17835.7800 69.8757
OCCT-97530HM-OT SESSION BY OT ASST 474 2465.637065 140734.0800 57.0782
OCCT-97530HMGT-OT SESSION BY OT ASST 32 51.000000 2888.6000 56.6392
OCCT-97530TL-OT SESSION BY LICENSED OT 3 3.000000 214.3200 71.4400
OCCT-97530TLGT-OT SESSION BY LICENSED OT 5 5.000000 357.2000 71.4400
PHY-97110-PT SESSION BY LICENSED PT 1441 7617.010079 535882.8900 70.3534
PHY-97110GT-PT SESSION BY LICENSED PT 164 215.000000 15147.9800 70.4557
PHY-97110HM-PT SESSION BY PT ASST 147 880.721486 50242.1300 57.0466
PHY-97110TLGT-PT SESSION BY LICENSED PT 6 7.000000 500.0800 71.4400
SENS-V5050-IN EAR MONAURAL HEARING AID 1 2.000000 456.0000 228.0000
SENS-V5140-BEHIND EAR BINAURAL HEARING AID 1 1.000000 456.0000 456.0000
SENS-V5264-EARMOLD 4 8.000000 144.0000 18.0000
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 2789 16562.59601 1166023.1586 70.4010
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 400 564.500000 40112.1000 71.0578
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 23 55.000000 2888.6400 52.5207
SPL-92507TL-SPL THERAPY SESSION BY LICENSED SLP 5 21.000000 1500.2400 71.4400
SPL-92507TLGT-SPL THERAPY SESSION BY LICENSED SLP 7 9.250000 660.8200 71.4400
SPL-92508-GROUP SPL SESSION PER CHILD 14 20.500000 370.8800 18.0917
TELEC-TELEC-TELECONFERENCE,PROVIDER TO FAMILY,PHONE 484 415.250000 15364.2500 37.0000
TRAV-TRAVS-Travel by mile 6559 591813.0000 259020.7200 0.4377
Subtotal (Total Children Is Unduplicated) 18323 834951.0605 8343833.9486 9.9932
-----------------------------------------------------------------------------------------------------------------------
Total 957243.561324 13160221.7385 13.7480
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 28201
-----------------------------------------------------------------------------------------------------------------------
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 21481 89739.500000 397960.7400 397960.7400
D 654 1458.750000 21363.4100 0.0000
S 6 5.000000 279.8800 0.0000
H 11496 8060.500000 351709.1200 315265.2400
T 863 3063.500000 21717.1600 21379.5200
8386 5401.000000 187319.5700 0.0000
Other 255 402.500000 26004.7500 0.0000
---------------------------------------------------------
Total 43141 108130.750000 1006354.6300 734605.5000
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 3 3.000000 100.0000 100.0000
H 0 0.000000 0.0000 0.0000
T 4608 19626.500000 112832.6100 112819.1700
100 265.500000 3111.5500 0.0000
Other 5616 15452.250000 114428.4700 0.0000
---------------------------------------------------------
Total 10327 35347.250000 230472.6300 112919.1700
Center 03
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 238 135.500000 5041.2500 0.0000
U 0 0.000000 0.0000 0.0000
B 3202 2278.250000 95633.5000 0.0000
P 2442 23295.250000 54236.3300 54236.3300
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 239 2110.000000 5986.7800 5986.7800
T 0 0.000000 0.0000 0.0000
9265 39803.750000 227936.2400 115.7000
Other 46 26.000000 962.0000 0.0000
---------------------------------------------------------
Total 15432 67648.750000 389796.1000 60338.8100
Center 04
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 37 50.750000 1877.7500 0.0000
U 0 0.000000 0.0000 0.0000
B 1268 1802.000000 70009.5000 101.7500
P 6756 17554.250000 408915.6400 398974.9300
D 2 2.000000 130.5000 0.0000
S 2 4.000000 148.0000 0.0000
H 2903 10028.500000 501926.4200 2920.0000
T 0 0.000000 0.0000 0.0000
4629 4424.250000 181543.2600 81.4600
Other 99 237.000000 12805.9900 1666.0000
---------------------------------------------------------
Total 15696 34102.750000 1177357.0600 403744.1400
Center 05
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 21 14.750000 685.7500 0.0000
U 0 0.000000 0.0000 0.0000
B 3197 2112.000000 81565.4500 55809.8700
P 8751 99409.750000 290785.9500 290785.9500
D 40 23.250000 898.2500 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
3475 2191.000000 62505.0800 4026.5800
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 15484 103750.750000 436440.4800 350622.4000
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 16328 15495.500000 359929.4400 359929.4400
D 1 0.750000 27.7500 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
20261 15149.500000 679252.0300 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 36590 30645.750000 1039209.2200 359929.4400
Center 07
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 26 127.000000 6129.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 977 726.250000 28448.7500 0.0000
P 9252 19777.247400 488641.7450 489336.1700
D 62 61.000000 3487.0500 0.0000
S 3 2.250000 96.2500 0.0000
H 27 53.000000 3951.0500 0.0000
T 0 0.000000 0.0000 0.0000
8014 4560.412600 137850.9950 0.0000
Other 1 0.250000 9.2500 0.0000
---------------------------------------------------------
Total 18362 25307.410000 668614.0900 489336.1700
Center 09
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 1 2.000000 150.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 183 179.750000 7152.7500 0.0000
P 24295 179313.000000 1148839.7800 1148943.1400
D 58 53.500000 2186.1400 0.0000
S 0 0.000000 0.0000 0.0000
H 550 786.500000 39152.2500 0.0000
T 0 0.000000 0.0000 0.0000
3072 12426.000000 489973.3800 0.0000
Other 217 364.000000 26797.2500 0.0000
---------------------------------------------------------
Total 28376 193124.750000 1714251.5500 1148943.1400
Center 10
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 139 107.500000 4459.2500 0.0000
U 0 0.000000 0.0000 0.0000
B 1083 814.250000 32301.7500 9.2500
P 20246 36990.000000 1061409.4300 1071168.4200
D 46 45.250000 2148.6900 0.0000
S 112 169.000000 5515.1300 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
12830 20580.000000 1049087.4400 0.0000
Other 76 147.500000 9990.0000 0.0000
---------------------------------------------------------
Total 34532 58853.500000 2164911.6900 1071177.6700
Center 51
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 1114 828.750000 34664.8300 0.0000
P 2168 9397.250000 162565.7000 162416.9500
D 14 12.500000 538.0000 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
3711 4240.250000 200434.8300 285.7600
Other 2 2.000000 146.4400 75.0000
---------------------------------------------------------
Total 7009 14480.750000 398349.8000 162777.7100
Center 52
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 5 3.250000 120.2500 0.0000
U 0 0.000000 0.0000 0.0000
B 326 305.750000 15224.9100 150.0000
P 1420 1465.000000 68796.9200 67626.8600
D 4 4.000000 200.0000 200.0000
S 544 522.000000 19966.0000 355.7500
H 157 212.000000 14320.6600 447.7600
T 6603 53030.000000 228734.4500 217290.4600
3359 4402.500000 209733.9500 439.0400
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 12418 59944.500000 557097.1400 286509.8700
Center 53
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 6 4.250000 170.2500 0.0000
U 0 0.000000 0.0000 0.0000
B 982 872.750000 38963.1500 1335.4400
P 3313 2912.750000 134087.3000 135809.2200
D 360 345.500000 21589.1200 71.4400
S 6 149.000000 66.3000 0.0000
H 0 0.000000 0.0000 0.0000
T 3305 26899.250000 45903.4500 45281.9500
15363 25229.000000 321759.5700 150.0000
Other 100 106.500000 7095.7400 0.0000
---------------------------------------------------------
Total 23435 56519.000000 569634.8800 182648.0500
Center 54
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 1418 1201.000000 56547.8000 157.2500
P 5349 4236.355924 185482.1900 191419.5700
D 363 332.394076 21577.5700 3.3000
S 0 0.000000 0.0000 0.0000
H 4 3.250000 126.7500 34.2500
T 9217 56506.380000 121111.5200 120705.5800
18666 32466.120000 418500.1700 0.0000
Other 108 104.750000 6835.4800 0.0000
---------------------------------------------------------
Total 35125 94850.250000 810181.4800 312319.9500
Center 55
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 1181 974.000000 40243.5300 129.5000
P 11437 14656.811421 279743.2600 295978.5600
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 10 18.000000 1342.8800 0.0000
T 479 658.500000 8022.9900 8022.9900
13913 12386.839903 538706.4785 0.0000
Other 4 4.000000 244.9800 0.0000
---------------------------------------------------------
Total 27024 28698.151324 868304.1185 304131.0500
Center 57
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 355 366.000000 15413.5000 18.5000
P 4684 4752.500000 190180.0800 187944.5020
D 14 7.000000 259.0000 0.0000
S 302 487.500000 11121.0400 11121.0400
H 16 15.750000 611.5000 75.0000
T 6176 27905.500000 361655.8200 361655.8200
7388 12232.250000 548618.1800 383628.6800
Other 44 72.750000 1387.7500 1387.7500
---------------------------------------------------------
Total 18979 45839.250000 1129246.8700 945831.2920