CMS/EIP Fiscal Report Statewide
Services beginning 04/01/2020 ending 06/30/2020 Date of Report:07/21/2020 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 12992 16605.75000 614128.0000 36.9829
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 269 247.500000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 7944 27045.25000 1000322.7500 36.9870
Subtotal (Total Children Is Unduplicated) 16940 43898.50000 1614450.7500 36.7769
-----------------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
ASTE-ASTE-ASSISTIVE TECHNOLOGY EVAL 22 22.000000 1067.0000 48.5000
AUDE-92552-PURE TONE AUDIOMETRY -AIR ONLY 4 4.000000 77.4800 19.3700
AUDE-92553-PURE TONE AUDIOMETRY AIR & BONE 1 1.000000 23.5000 23.5000
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 5 5.000000 72.9000 14.5800
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 5 5.000000 48.9500 9.7900
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 5 5.000000 143.6000 28.7200
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 1 1.000000 13.7100 13.7100
AUDE-92588-OTOACOUSTIC EMISSIONS (COMP) 2 2.000000 41.7800 20.8900
AUDE-V5010-ASSESSMENT FOR HEARING AID 3 3.000000 135.0000 45.0000
AUDE-V5090-DISPENSING FEE PER HEARING AID 1 2.000000 230.0000 115.0000
EVAL-96111-DEVELOPMENTAL EVALUATION 46 72.250000 3612.5000 50.0000
EVAL-96111GT-DEVELOPMENTAL EVALUATION 6 9.000000 450.0000 50.0000
EXIT-EXIT-EXIT ASSESSMENT 307 507.000000 25350.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 10 15.000000 1125.0000 75.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 19 31.000000 2325.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 1.000000 75.0000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 12 19.500000 1462.5000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 4 5.000000 375.0000 75.0000
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 11 18.000000 1350.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 6 7.500000 562.5000 75.0000
IPDEF-T1024TLTSGT-F/U PHYC AND DEV EVAL BY EI PROF 8 13.500000 1012.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 29 48.000000 2664.0000 55.5000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 65 101.000000 5605.5000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 18 26.500000 1987.5000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 232 402.506933 30080.0600 74.7318
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 6 10.000000 750.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 113 181.955335 13646.6500 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 6 9.500000 712.5000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 120 216.333333 16225.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 29 44.000000 2442.0000 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 412 704.000000 39072.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 13 23.833333 1787.5000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 129 220.500000 16537.5000 75.0000
NUTR-97803-NUTRITIONAL EVAL, FOLLOW-UP 13 77.000000 3850.0000 50.0000
OCTF-97168-OT RE-EVAL EST PLAN CARE 2 1.140059 58.2000 51.0500
OCTH-97166GT-OT EVAL MODERATE COMPLEXITY 6 6.000000 306.3000 51.0500
OCTH-97167-OT EVAL HIGH COMPLEXITY 3 3.000000 153.1500 51.0500
OCTH-97167GT-OT EVAL HIGH COMPLEXITY 7 7.000000 357.3500 51.0500
PSTF-97164GT-PT RE-EVAL EST PLAN CARE 2 2.000000 102.1000 51.0500
PSTH-97161-PT EVAL LOW COMPLEXITY 1 1.000000 51.0500 51.0500
PSTH-97162-PT EVAL MODERATE COMPLEXITY 2 2.000000 102.1000 51.0500
PSTH-97163-PT EVAL HIGH COMPLEXITY 6 6.000000 306.3000 51.0500
PSTH-97163GT-PT EVAL HIGH COMPLEXITY 1 1.000000 51.0500 51.0500
SCREEN-T1023-SCREENING 15 15.000000 750.0000 50.0000
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 18 16.824681 858.9000 51.0500
SPCH-92523GT-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 9 9.000000 459.4500 51.0500
SPCH-92523TLGT-EVAL OF SPCH SOUND PROD; EVAL LANG COM 1 1.000000 51.0500 51.0500
SPCH-92524-BEHAV & QUAL ANALYSIS OF VOICE AND RES 7 7.000000 357.3500 51.0500
SPCH-92524GT-BEHAV & QUAL ANALYSIS OF VOICE AND RES 9 9.000000 459.4500 51.0500
SPCH-92610GT-EVAL OF ORAL,PHARYNGEAL SWALLOWING FUNC 2 2.000000 89.1000 44.5500
Subtotal (Total Children Is Unduplicated) 1255 2902.843674 179427.0300 61.8108
-----------------------------------------------------------------------------------------------------------------------
EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 24 44.000000 17662.8100 401.4275
AUDE-V5160-DISPENSING FEE BINAURAL 1 1.000000 230.0000 230.0000
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 387 450.250000 22512.5000 50.0000
COIFF-COIFFGT-IFSP CONSULT,PROF,FACE TO FACE 787 964.250000 48187.5000 49.9741
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 665 716.750000 17900.0000 24.9738
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 590 604.250000 30162.5000 49.9173
CONIF-CONIFGT-CONSULT,ITDS,FACE TO FACE 1567 2189.250000 109450.0000 49.9943
CONIP-CONIP-CONSULT, ITDS PHONE 184 205.000000 5125.0000 25.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 244 192.500000 9625.0000 50.0000
CONOF-CONOFGT-CONSULT,OT,FACE TO FACE 975 844.500000 42188.0000 49.9562
CONOP-CONOP-CONSULT, OT, PHONE 95 113.750000 2843.7500 25.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 181 152.250000 7612.5000 50.0000
CONPF-CONPFGT-CONSULT,PT,FACE TO FACE 588 510.750000 25537.5000 50.0000
CONPP-CONPP-CONSULT, PT, PHONE 62 34.250000 850.0000 24.8175
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 341 310.750000 15387.5000 49.5173
CONSF-CONSFGT-CONSULT,SLP,FACE TO FACE 1189 1283.000000 64137.5000 49.9903
CONSP-CONSP-CONSULT, SLP, PHONE 143 134.750000 3368.7500 25.0000
DSTT-DSTT-DIRECT SERVICE COORDINATOR TRAVEL 55 57.250000 0.0000 0.0000
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 2 1.500000 37.5000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 959 4580.000000 219450.0000 47.9148
CMS/EIP Fiscal Report Statewide
Services beginning 04/01/2020 ending 06/30/2020 Date of Report:07/21/2020 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
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 1900 11742.25000 585562.5000 49.8680
INTR-T1013-INTERPRETER 152 620.500000 31000.2500 49.9601
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 4108 21692.00000 216775.0000 9.9933
OCCT-97530-OT SESSION BY LICENSED OT 162 649.111561 45385.6600 69.9197
OCCT-97530GT-OT SESSION BY LICENSED OT 211 903.685890 63635.1700 70.4174
OCCT-97530HM-OT SESSION BY OT ASST 15 45.242832 2587.8900 57.2000
OCCT-97530HMGT-OT SESSION BY OT ASST 26 96.409790 5514.6400 57.2000
PHY-97110-PT SESSION BY LICENSED PT 201 987.250000 65598.3200 66.4455
PHY-97110GT-PT SESSION BY LICENSED PT 213 841.736282 59302.2400 70.4523
PHY-97110HM-PT SESSION BY PT ASST 5 27.000000 1543.3200 57.1600
PHY-97110HMGT-PT SESSION BY LICENSED PT ASST 5 9.822078 561.4300 57.1600
PHY-97110TLGT-PT SESSION BY LICENSED PT 1 1.500000 107.1600 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 3 6.000000 108.0000 18.0000
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 325 1389.104140 97812.0000 70.4137
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 487 2601.411954 182247.0100 70.0570
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 2 3.000000 20.8400 6.9467
SPL-92507TLGT-SPL THERAPY SESSION BY LICENSED SLP 2 3.500000 250.0400 71.4400
TELEC-TELEC-TELECONFERENCE,PROVIDER TO FAMILY,PHONE 824 1433.750000 53048.7500 37.0000
TRAV-TRAVS-Travel by mile 1785 108650.0000 48023.9100 0.4420
Subtotal (Total Children Is Unduplicated) 9514 165096.2745 2102264.4400 12.7336
-----------------------------------------------------------------------------------------------------------------------
Total 211897.618201 3896142.2200 18.3869
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 19898
-----------------------------------------------------------------------------------------------------------------------
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 2818 8552.500000 69707.6600 69707.6600
D 395 1537.000000 5876.6100 0.0000
S 17 8.000000 296.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 3173 12491.250000 57584.7500 57609.7500
7331 4484.000000 175343.7600 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 13734 27072.750000 308808.7800 127317.4100
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 1181 2125.250000 43692.6900 43692.6900
928 2901.000000 26907.7600 0.0000
Other 3224 1496.750000 61026.5000 0.0000
---------------------------------------------------------
Total 5333 6523.000000 131626.9500 43692.6900
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 365 1744.000000 13458.7400 13458.7400
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 83 937.500000 3019.8000 3019.8000
T 0 0.000000 0.0000 0.0000
6130 15774.250000 176733.9900 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 6578 18455.750000 193212.5300 16478.5400
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 1360 4930.750000 109799.3700 108089.3700
D 3 5.500000 203.5000 0.0000
S 1 0.500000 18.5000 0.0000
H 22 71.000000 950.0000 900.0000
T 0 0.000000 0.0000 0.0000
3457 3234.250000 126074.2500 0.0000
Other 6 14.500000 747.2400 568.6400
---------------------------------------------------------
Total 4849 8256.500000 237792.8600 109558.0100
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 3298 32178.250000 124695.9300 124695.9300
D 34 23.250000 917.2500 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
2801 3610.000000 60255.3600 5791.3600
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 6133 35811.500000 185868.5400 130487.2900
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 5036 4876.750000 150953.6300 150953.6300
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
8893 5492.000000 177566.6400 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 13929 10368.750000 328520.2700 150953.6300
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 1829 4115.750000 134333.5000 134327.2500
D 35 16.750000 619.7500 0.0000
S 0 0.000000 0.0000 0.0000
H 2 4.000000 300.0000 0.0000
T 0 0.000000 0.0000 0.0000
7117 3576.750000 135414.5000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 8983 7713.250000 270667.7500 134327.2500
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 8321 20570.000000 432277.8100 432277.8100
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
4820 22457.250000 249141.5000 9.2500
Other 11 22.000000 1572.0000 0.0000
---------------------------------------------------------
Total 13152 43049.250000 682991.3100 432287.0600
Center 10
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 4 2.000000 74.0000 0.0000
P 4084 10244.000000 449849.1400 449964.8900
D 21 21.750000 933.2900 0.0000
S 24 29.750000 1532.2500 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
5087 3532.250000 134770.5000 0.0000
Other 35 56.500000 3886.5000 0.0000
---------------------------------------------------------
Total 9255 13886.250000 591045.6800 449964.8900
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 243 781.000000 28708.9100 28708.9100
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
1416 969.000000 37295.7100 10.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 1659 1750.000000 66004.6200 28718.9100
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 0 0.000000 0.0000 0.0000
D 0 0.000000 0.0000 0.0000
S 9 7.500000 314.5000 0.0000
H 0 0.000000 0.0000 0.0000
T 1955 12900.500000 55709.7800 53675.5100
1994 1401.250000 50410.5000 92.5000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 3958 14309.250000 106434.7800 53768.0100
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 19 13.750000 543.1900 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 437 303.000000 13035.3300 13035.3300
6466 3675.750000 151445.4400 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 6922 3992.500000 165023.9600 13035.3300
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 3 0.750000 27.7500 27.7500
D 1 0.250000 9.2500 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 1372 1297.750000 33750.7800 33723.0300
8252 4733.750000 202580.5000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 9628 6032.500000 236368.2800 33750.7800
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 3040 4863.273121 65363.9800 65381.2000
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 3 3.250000 209.2500 0.0000
T 0 0.000000 0.0000 0.0000
6334 4946.595080 141950.2800 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 9377 9813.118201 207523.5100 65381.2000
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 4 1.000000 37.0000 37.0000
D 2 1.750000 64.7500 64.7500
S 5 5.500000 242.5000 242.5000
H 0 0.000000 0.0000 0.0000
T 697 987.500000 43025.4000 43025.4000
4704 3866.000000 140827.2500 100.0000
Other 2 1.500000 55.5000 55.5000
---------------------------------------------------------
Total 5414 4863.250000 184252.4000 43525.1500