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
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 13756 15937.50000 589530.2500 36.9901
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 6957 6620.500000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 8955 28647.50000 1059302.7500 36.9771
Subtotal (Total Children Is Unduplicated) 20103 51205.50000 1648833.0000 32.2003
-----------------------------------------------------------------------------------------------------------------------
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 29 30.000000 588.6600 19.6220
AUDE-92553-PURE TONE AUDIOMETRY AIR & BONE 1 1.000000 23.4900 23.4900
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 34 35.000000 505.4500 14.4414
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 27 28.000000 262.0400 9.3586
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 33 34.000000 970.4600 28.5429
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 14 14.000000 209.0500 14.9321
AUDE-92588-OTOACOUSTIC EMISSIONS (COMP) 8 9.000000 193.0500 21.4500
AUDE-V5010-ASSESSMENT FOR HEARING AID 1 1.000000 45.0000 45.0000
AUDE-V5090-DISPENSING FEE PER HEARING AID 1 2.000000 230.0000 115.0000
EVAL-96111-DEVELOPMENTAL EVALUATION 54 67.750000 3387.5000 50.0000
EXIT-EXIT-EXIT ASSESSMENT 931 1436.250000 71812.5000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 34 56.000000 4117.9000 73.5339
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 13 20.000000 1462.5000 73.1250
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 6 8.500000 637.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 24 29.000000 2175.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 90 124.500000 6909.7500 55.5000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 4 4.000000 222.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 528 845.274332 63244.5249 74.8213
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 14 16.836800 1262.7600 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 218 334.252266 25068.9200 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 7 9.500000 712.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 167 272.028534 20402.1400 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 4 5.500000 412.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 783 1128.000000 62581.7500 55.4803
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 6 10.000000 555.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 225 350.700800 26190.0600 74.6792
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 3 5.000000 375.0000 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 1 0.118511 6.0500 51.0501
OCTH-97165-OT EVAL LOW COMPLEXITY 7 7.000000 357.3500 51.0500
OCTH-97165GT-OT EVAL LOW COMPLEXITY 1 1.000000 51.0500 51.0500
OCTH-97166-OT EVAL MODERATE COMPLEXITY 13 13.000000 608.5900 46.8146
OCTH-97167-OT EVAL HIGH COMPLEXITY 54 54.000000 2730.3400 50.5619
PSTH-97161-PT EVAL LOW COMPLEXITY 1 1.000000 51.0500 51.0500
PSTH-97162-PT EVAL MODERATE COMPLEXITY 5 5.000000 255.2500 51.0500
PSTH-97163-PT EVAL HIGH COMPLEXITY 17 18.000000 918.9000 51.0500
SCREEN-T1023-SCREENING 60 61.000000 3050.0000 50.0000
SPCH-92521-EVAL OF SPEECH FLUENCY 3 3.000000 153.1500 51.0500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 61 60.510284 2980.9100 49.2629
SPCH-92523GT-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 1 1.000000 51.0500 51.0500
SPCH-92524-BEHAV & QUAL ANALYSIS OF VOICE AND RES 14 14.000000 714.7000 51.0500
Subtotal (Total Children Is Unduplicated) 2524 5215.721527 311443.3949 59.7124
-----------------------------------------------------------------------------------------------------------------------
EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 18 32.000000 8437.7000 263.6781
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 1561 1914.500000 95497.5000 49.8812
COIFF-COIFFGT-IFSP CONSULT,PROF,FACE TO FACE 41 54.500000 2725.0000 50.0000
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 202 199.500000 4987.5000 25.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 1925 2689.750000 134450.0000 49.9861
CONIF-CONIFGT-CONSULT,ITDS,FACE TO FACE 188 122.750000 6100.0000 49.6945
CONIP-CONIP-CONSULT, ITDS PHONE 242 235.500000 5887.5000 25.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 1101 1080.750000 54037.5000 50.0000
CONOF-CONOFGT-CONSULT,OT,FACE TO FACE 42 31.000000 1550.0000 50.0000
CONOP-CONOP-CONSULT, OT, PHONE 112 190.250000 4750.0000 24.9671
CONPF-CONPF-CONSULT, PT, FACE TO FACE 637 566.000000 28300.0000 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 1396 1486.500000 74137.5000 49.8739
CONSF-CONSFGT-CONSULT,SLP,FACE TO FACE 50 40.500000 2025.0000 50.0000
CONSP-CONSP-CONSULT, SLP, PHONE 137 105.250000 2631.2500 25.0000
DSTT-DSTT-DIRECT SERVICE COORDINATOR TRAVEL 1981 4378.250000 0.0000 0.0000
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 26 98.500000 2462.5000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 3336 21588.75000 1076412.5000 49.8599
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 639 1009.750000 50487.5000 50.0000
INTR-T1013-INTERPRETER 508 1389.910000 69378.7400 49.9160
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 14370 112114.0000 1120333.5800 9.9928
OCCT-97530-OT SESSION BY LICENSED OT 406 1860.535132 131385.1000 70.6168
OCCT-97530GT-OT SESSION BY LICENSED OT 56 70.500000 4844.3600 68.7143
OCCT-97530HM-OT SESSION BY OT ASST 103 521.737417 29728.9800 56.9807
OCCT-97530HMGT-OT SESSION BY OT ASST 7 21.750000 1244.1000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 443 2103.421752 147520.6800 70.1337
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
Payclass Filters:GR
Eligibility Filter:Program Patients
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
PHY-97110GT-PT SESSION BY LICENSED PT 47 45.000000 3174.8000 70.5511
PHY-97110HM-PT SESSION BY PT ASST 20 95.288665 5446.7000 57.1600
SENS-V5050-IN EAR MONAURAL HEARING AID 1 2.000000 456.0000 228.0000
SENS-V5264-EARMOLD 1 2.000000 36.0000 18.0000
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 905 4885.805441 341366.9400 69.8691
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 135 195.750000 13915.9400 71.0904
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 4 14.000000 543.4400 38.8171
SPL-92507TLGT-SPL THERAPY SESSION BY LICENSED SLP 1 1.000000 71.4400 71.4400
SPL-92508-GROUP SPL SESSION PER CHILD 2 2.000000 27.7600 13.8800
TELEC-TELEC-TELECONFERENCE,PROVIDER TO FAMILY,PHONE 484 415.250000 15364.2500 37.0000
TRAV-TRAVS-Travel by mile 6359 549668.0000 240703.3200 0.4379
Subtotal (Total Children Is Unduplicated) 17544 709265.4484 3681671.0800 5.1908
-----------------------------------------------------------------------------------------------------------------------
Total 765686.669934 5641947.4749 7.3685
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 25389
-----------------------------------------------------------------------------------------------------------------------
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 18766 86984.500000 246026.0900 246026.0900
D 394 1194.500000 6260.3100 0.0000
S 1 0.500000 18.5000 0.0000
H 0 0.000000 0.0000 0.0000
T 682 2877.250000 10223.9800 10223.9800
8102 5093.500000 168279.0600 0.0000
Other 3 5.000000 345.7500 0.0000
---------------------------------------------------------
Total 27948 96155.250000 431153.6900 256250.0700
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 4306 19337.500000 92399.4000 92407.4000
80 250.250000 2022.0900 0.0000
Other 3842 14295.750000 64069.9700 0.0000
---------------------------------------------------------
Total 8231 33886.500000 158591.4600 92507.4000
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 2424 23277.750000 53119.6900 53119.6900
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 235 2106.000000 5701.0200 5701.0200
T 0 0.000000 0.0000 0.0000
9059 39572.250000 212687.3000 115.7000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 11718 64956.000000 271508.0100 58936.4100
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 3854 13009.750000 218723.9000 218723.9000
D 1 1.000000 55.5000 0.0000
S 0 0.000000 0.0000 0.0000
H 81 243.000000 2990.0000 2920.0000
T 0 0.000000 0.0000 0.0000
3886 3475.750000 137740.8000 0.0000
Other 24 67.000000 1666.0000 1666.0000
---------------------------------------------------------
Total 7846 16796.500000 361176.2000 223309.9000
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 8485 98956.500000 262538.0000 262538.0000
D 39 22.250000 861.2500 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
3466 2176.000000 61463.2600 2984.7600
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 11990 101154.750000 324862.5100 265522.7600
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 14918 14683.750000 304580.9300 304580.9300
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
7760 4446.000000 147121.6300 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 22679 19130.500000 451730.3100 304580.9300
Center 07
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 5 3.250000 120.2500 0.0000
U 0 0.000000 0.0000 0.0000
B 0 0.000000 0.0000 0.0000
P 5446 15938.160000 300884.5500 300884.5500
D 45 28.000000 1036.0000 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
7936 4494.662600 134790.4950 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 13440 20480.072600 438031.2950 300884.5500
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 17306 130113.750000 732419.3300 732400.8300
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
141 3467.000000 10386.7200 0.0000
Other 6 9.500000 687.5000 0.0000
---------------------------------------------------------
Total 17453 133590.250000 743493.5500 732400.8300
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 10518 29268.000000 731212.0000 731212.0000
D 26 25.000000 1178.7200 0.0000
S 98 134.000000 3765.1300 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
6540 5031.250000 167491.5000 0.0000
Other 76 147.500000 9990.0000 0.0000
---------------------------------------------------------
Total 17258 34605.750000 913637.3500 731212.0000
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 1576 8485.250000 109808.7600 109808.7600
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
2984 2190.000000 76634.4500 285.7600
Other 1 1.000000 75.0000 75.0000
---------------------------------------------------------
Total 4561 10676.250000 186518.2100 110169.5200
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 18.250000 17.2600 17.2600
D 0 0.000000 0.0000 0.0000
S 57 47.750000 1766.7500 0.0000
H 0 0.000000 0.0000 0.0000
T 5659 51522.250000 135533.8800 130966.0400
1835 1338.250000 41010.9100 30.9100
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 7553 52926.500000 178328.8000 131014.2100
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 2 1.000000 37.0000 37.0000
D 19 19.500000 803.3800 0.0000
S 6 149.000000 66.3000 0.0000
H 0 0.000000 0.0000 0.0000
T 3255 26847.750000 43304.5300 42933.0300
12936 22683.250000 180953.6300 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 16218 49700.500000 225164.8400 42970.0300
Center 54
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 9.2500 0.0000
P 2 1.250000 18.5000 74.0000
D 26 23.000000 1504.1900 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 8947 56232.000000 105498.4000 105092.4600
14687 28176.000000 203297.3300 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 23663 84432.500000 310327.6700 105166.4600
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 7185 11281.061421 127441.8300 127441.8300
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 459 639.000000 6936.7100 6936.7100
7487 5875.785913 149871.8899 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 15131 17795.847334 284250.4299 134378.5400
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 3 1.000000 37.0000 37.0000
D 1 0.500000 18.5000 0.0000
S 275 468.000000 9917.0400 9917.0400
H 1 0.250000 0.0000 0.0000
T 5135 24874.500000 209547.3600 209547.3600
4552 4055.250000 143653.2500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 9967 29399.500000 363173.1500 219501.4000