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:TPIN
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 3 0.750000 27.7500 37.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 45 136.000000 4985.7500 36.6599
Subtotal (Total Children Is Unduplicated) 46 136.750000 5013.5000 36.6618
-----------------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
AUDE-92552-PURE TONE AUDIOMETRY -AIR ONLY 18 20.000000 352.7400 17.6370
AUDE-92553-PURE TONE AUDIOMETRY AIR & BONE 2 2.000000 47.2600 23.6300
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 26 28.000000 380.6200 13.5936
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 17 18.000000 166.7100 9.2617
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 27 30.000000 805.5000 26.8500
AUDE-92582-CONDITIONED PLAY AUDIOMETRY 1 1.000000 38.4700 38.4700
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 5 5.000000 93.7100 18.7420
AUDE-92588-OTOACOUSTIC EMISSIONS (COMP) 7 7.000000 144.8300 20.6900
AUDE-V5010-ASSESSMENT FOR HEARING AID 1 1.000000 45.0000 45.0000
EVAL-96111-DEVELOPMENTAL EVALUATION 3 5.000000 250.0000 50.0000
EXIT-EXIT-EXIT ASSESSMENT 2 3.000000 150.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 39 60.000000 4500.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 13 21.000000 1575.0000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 1 1.500000 112.5000 75.0000
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 28 52.500000 4790.9600 91.2564
IPDEF-T1024TLTSGT-F/U PHYC AND DEV EVAL BY EI PROF 1 2.000000 150.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 46 81.000000 4495.5000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 689 1222.648864 90595.3150 74.0976
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 9 17.500000 1312.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 263 461.484266 33983.7200 73.6400
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 2 3.500000 262.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 207 333.133333 24538.3500 73.6592
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 3 4.000000 300.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 709 1232.000000 67968.0000 55.1688
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 16 29.000000 1554.0000 53.5862
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 307 494.641600 42049.4100 85.0099
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 5 10.000000 750.0000 75.0000
OCTF-97168-OT RE-EVAL EST PLAN CARE 3 2.881489 147.1000 51.0500
OCTH-97165-OT EVAL LOW COMPLEXITY 1 1.000000 51.0500 51.0500
OCTH-97166-OT EVAL MODERATE COMPLEXITY 10 11.000000 496.1400 45.1036
OCTH-97167-OT EVAL HIGH COMPLEXITY 38 39.000000 1820.2200 46.6723
PSTF-97164-PT RE-EVAL EST PLAN CARE 3 3.000000 153.1500 51.0500
PSTH-97161-PT EVAL LOW COMPLEXITY 1 1.000000 51.0500 51.0500
PSTH-97162-PT EVAL MODERATE COMPLEXITY 7 7.000000 357.3500 51.0500
PSTH-97163-PT EVAL HIGH COMPLEXITY 18 18.000000 906.9000 50.3833
SCREEN-T1023-SCREENING 26 27.000000 1300.0000 48.1481
SPCH-92521-EVAL OF SPEECH FLUENCY 1 1.000000 51.0500 51.0500
SPCH-92522-EVAL OF SPCH SOUND PROD 1 1.000000 51.0500 51.0500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 79 81.489716 4089.5000 50.1842
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 9 9.000000 459.4500 51.0500
SPCH-92610-EVAL OF ORAL,PHARYNGEAL SWALLOWING FUNC 5 8.000000 246.1900 30.7738
Subtotal (Total Children Is Unduplicated) 1460 4365.779268 292281.3450 66.9483
-----------------------------------------------------------------------------------------------------------------------
EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 2 2.000000 1281.9400 640.9700
AUD-92593TS-AUDIOLOGY SERVICES (Biaural) 1 1.000000 50.0000 50.0000
AUDE-V5160-DISPENSING FEE BINAURAL 1 1.000000 230.0000 230.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 10 10.000000 500.0000 50.0000
CONIP-CONIP-CONSULT, ITDS PHONE 55 35.500000 887.5000 25.0000
CONOP-CONOP-CONSULT, OT, PHONE 5 5.000000 125.0000 25.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 1 1.000000 50.0000 50.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 10 10.000000 500.0000 50.0000
CONSP-CONSP-CONSULT, SLP, PHONE 30 22.000000 550.0000 25.0000
DSTT-DSTT-DIRECT SERVICE COORDINATOR TRAVEL 3 4.750000 0.0000 0.0000
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 4 6.000000 150.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 1160 7532.250000 366472.5000 48.6538
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 176 209.000000 10450.0000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 8 12.000000 120.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 460 2130.150758 144300.8600 67.7421
OCCT-97530GT-OT SESSION BY LICENSED OT 55 79.000000 5447.3200 68.9534
OCCT-97530HM-OT SESSION BY OT ASST 121 566.649648 32283.6000 56.9728
OCCT-97530HMGT-OT SESSION BY OT ASST 14 15.500000 858.0000 55.3548
PHY-97110-PT SESSION BY LICENSED PT 443 2152.338327 148450.5600 68.9718
PHY-97110GT-PT SESSION BY LICENSED PT 59 84.750000 5882.9200 69.4150
PHY-97110HM-PT SESSION BY PT ASST 25 134.682821 7598.5600 56.4182
SENS-V5140-BEHIND EAR BINAURAL HEARING AID 1 1.000000 456.0000 456.0000
SENS-V5264-EARMOLD 3 6.000000 108.0000 18.0000
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 1041 5371.130434 374497.6286 69.7242
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 135 158.000000 11212.0200 70.9622
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 6 8.000000 457.6000 57.2000
SPL-92508-GROUP SPL SESSION PER CHILD 5 5.500000 162.6800 29.5782
TRAV-TRAVS-Travel by mile 1 17.000000 7.3400 0.4318
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:TPIN
Eligibility Filter:Program Patients
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Subtotal (Total Children Is Unduplicated) 2848 18581.20199 1113090.0286 59.9041
-----------------------------------------------------------------------------------------------------------------------
Total 23083.731256 1410384.8736 61.0987
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 3834
-----------------------------------------------------------------------------------------------------------------------
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 2713 2753.250000 151869.9000 151869.9000
D 98 97.500000 6002.5000 0.0000
S 3 3.000000 171.4400 0.0000
H 477 533.750000 36022.9800 0.0000
T 181 186.250000 11493.1800 11155.5400
283 306.000000 18928.0100 0.0000
Other 22 36.500000 2542.5000 0.0000
---------------------------------------------------------
Total 3777 3916.250000 227030.5100 163025.4400
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 302 289.000000 20433.2100 20411.7700
20 15.250000 1089.4600 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 322 304.250000 21522.6700 20411.7700
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 18 17.500000 1116.6400 1116.6400
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 4 4.000000 285.7600 285.7600
T 0 0.000000 0.0000 0.0000
138 160.000000 10435.6600 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 160 181.500000 11838.0600 1402.4000
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 143 266.500000 23365.0700 15913.7200
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 12 46.000000 2329.8500 0.0000
T 0 0.000000 0.0000 0.0000
52 52.250000 3664.9600 81.4600
Other 71 164.000000 10917.9900 0.0000
---------------------------------------------------------
Total 278 528.750000 40277.8700 15995.1800
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 265 451.250000 28147.9500 28147.9500
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
9 15.000000 1041.8200 1041.8200
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 274 466.250000 29189.7700 29189.7700
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 1410 811.750000 55348.5100 55348.5100
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
932 884.000000 59709.7400 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 2342 1695.750000 115058.2500 55348.5100
Center 07
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 2 0.500000 18.5000 0.0000
P 439 1004.087400 67897.9450 67897.9200
D 17 33.000000 2451.0500 0.0000
S 3 2.250000 96.2500 0.0000
H 19 37.000000 2751.0500 0.0000
T 0 0.000000 0.0000 0.0000
23 27.000000 1612.7000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 503 1103.837400 74827.4950 67897.9200
Center 09
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 2 3.000000 225.0000 0.0000
P 505 906.000000 60079.1400 60201.0000
D 6 6.000000 428.6400 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
192 460.000000 32147.8200 0.0000
Other 38 60.000000 4470.7500 0.0000
---------------------------------------------------------
Total 743 1435.000000 97351.3500 60201.0000
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 803 589.000000 32267.5700 32267.5700
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
1078 1888.500000 126504.5500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 1881 2477.500000 158772.1200 32267.5700
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 211 604.500000 40668.4400 40668.4400
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 49.500000 3515.8900 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 227 654.000000 44184.3300 40668.4400
Center 52
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 2 2.000000 100.0000 0.0000
P 36 50.000000 3525.5000 2528.9800
D 4 4.000000 200.0000 200.0000
S 4 6.000000 311.0000 122.5000
H 122 170.000000 11501.9800 0.0000
T 942 1503.750000 92914.8100 86252.9800
347 531.500000 30445.5900 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 1457 2267.250000 138998.8800 89104.4600
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 0 0.000000 0.0000 0.0000
D 120 122.000000 7261.3200 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 50 51.500000 2598.9200 2348.9200
870 925.250000 55733.8400 0.0000
Other 79 81.500000 5438.4600 0.0000
---------------------------------------------------------
Total 1119 1180.250000 71032.5400 2348.9200
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 4 1.105924 78.7200 69.8200
D 124 123.394076 8673.0400 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 270 274.380000 15613.1200 15613.1200
536 760.870000 34893.0100 0.0000
Other 41 40.250000 2875.4600 0.0000
---------------------------------------------------------
Total 975 1200.000000 62133.3500 15682.9400
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 547 536.250000 36078.6800 36078.6800
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 20 19.500000 1086.2800 1086.2800
1195 1114.393856 69926.8486 0.0000
Other 1 1.000000 51.0500 0.0000
---------------------------------------------------------
Total 1773 1689.143856 108485.7386 37164.9600
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 217 123.500000 7766.0800 7756.8300
D 0 0.000000 0.0000 0.0000
S 26 16.500000 1093.0000 1093.0000
H 11 10.750000 397.7500 0.0000
T 1041 3031.000000 152108.4600 152108.4600
512 802.250000 48316.6500 26930.4000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 1807 3984.000000 209681.9400 187888.6900