CMS/EIP Fiscal Report Statewide
Services beginning 07/01/2019 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 32494 62886.50000 2326017.0000 36.9875
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 19082 22212.00000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 18233 110258.5000 4077130.0000 36.9779
Subtotal (Total Children Is Unduplicated) 42541 195357.0000 6403147.0000 32.7766
-----------------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
ASTE-ASTE-ASSISTIVE TECHNOLOGY EVAL 95 114.000000 5529.0000 48.5000
AUDE-92552-PURE TONE AUDIOMETRY -AIR ONLY 175 195.000000 3818.6500 19.5828
AUDE-92553-PURE TONE AUDIOMETRY AIR & BONE 3 3.000000 70.7700 23.5900
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 197 221.000000 3217.4300 14.5585
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 187 211.000000 1990.5600 9.4339
AUDE-92568-ACOUSTIC REFLEX TESTING (MEMR) 3 3.000000 29.8800 9.9600
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 199 221.000000 6340.4100 28.6896
AUDE-92582-CONDITIONED PLAY AUDIOMETRY 1 1.000000 38.4700 38.4700
AUDE-92585-AUD EVOKED RESPONSE (COMP) 4 4.000000 322.0100 80.5025
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 75 75.000000 1116.7900 14.8905
AUDE-92588-OTOACOUSTIC EMISSIONS (COMP) 67 81.000000 1683.9300 20.7893
AUDE-V5010-ASSESSMENT FOR HEARING AID 6 9.000000 405.0000 45.0000
AUDE-V5090-DISPENSING FEE PER HEARING AID 4 8.000000 765.0000 95.6250
EVAL-96111-DEVELOPMENTAL EVALUATION 299 385.500000 19286.0000 50.0285
EVAL-96111GT-DEVELOPMENTAL EVALUATION 6 9.000000 450.0000 50.0000
EXIT-EXIT-EXIT ASSESSMENT 3302 5163.000000 257575.0000 49.8886
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 142 213.008267 15723.9200 73.8184
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 51 69.492666 5174.4500 74.4604
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 36 58.000000 4330.5000 74.6638
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 74 107.500000 8062.5000 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 277 399.000000 22144.5000 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 1723 2724.155000 202570.7549 74.3610
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 247 420.173600 31405.0600 74.7431
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 712 1073.383468 80503.7601 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 120 191.455335 14359.1500 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 624 983.407201 73755.5400 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 124 221.833333 16637.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 2699 3908.500000 216817.6900 55.4734
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 420 716.000000 39738.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 853 1307.798533 97698.7775 74.7048
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 133 226.500000 16987.5000 75.0000
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 26 26.000000 1531.6600 58.9100
MED-99204-OUTPATIENT VISIT, NEW, 45 MINS 2 2.000000 166.5800 83.2900
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 4 4.000000 93.6800 23.4200
MED-99214-OUTPATIENT VISIT, EST, 25 MINS 1 1.000000 36.4900 36.4900
NUTR-97802-NUTRITIONAL EVAL, INITIAL 3 10.000000 500.0000 50.0000
NUTR-97803-NUTRITIONAL EVAL, FOLLOW-UP 19 170.000000 8500.0000 50.0000
OCTF-97168-OT RE-EVAL EST PLAN CARE 13 13.799804 619.1300 44.8651
OCTH-97165-OT EVAL LOW COMPLEXITY 18 18.000000 918.9000 51.0500
OCTH-97166-OT EVAL MODERATE COMPLEXITY 63 64.000000 3171.5400 49.5553
OCTH-97166GT-OT EVAL MODERATE COMPLEXITY 6 6.000000 306.3000 51.0500
OCTH-97167-OT EVAL HIGH COMPLEXITY 182 187.269344 9378.3200 50.0793
OCTH-97167GT-OT EVAL HIGH COMPLEXITY 8 8.000000 408.4000 51.0500
PSTF-97164-PT RE-EVAL EST PLAN CARE 9 10.000000 408.4000 40.8400
PSTF-97164GT-PT RE-EVAL EST PLAN CARE 2 2.000000 102.1000 51.0500
PSTH-97161-PT EVAL LOW COMPLEXITY 12 10.000000 510.5000 51.0500
PSTH-97162-PT EVAL MODERATE COMPLEXITY 28 28.000000 1429.4000 51.0500
PSTH-97163-PT EVAL HIGH COMPLEXITY 90 93.000000 4597.6600 49.4372
PSTH-97163GT-PT EVAL HIGH COMPLEXITY 1 1.000000 51.0500 51.0500
SCREEN-T1023-SCREENING 241 272.000000 13600.0000 50.0000
SPCH-92521-EVAL OF SPEECH FLUENCY 5 5.000000 235.2500 47.0500
SPCH-92522-EVAL OF SPCH SOUND PROD 13 13.000000 570.2400 43.8646
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 250 255.509500 12778.3500 50.0113
SPCH-92523GT-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 11 11.000000 561.5500 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 46 47.000000 2399.3500 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) 9213 20776.28605 1223778.4525 58.9027
-----------------------------------------------------------------------------------------------------------------------
EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 112 267.000000 62555.8000 234.2914
AUD-92592TS-AUDIOLOGY SERVICES (Monaural) 1 1.000000 50.0000 50.0000
AUD-92593TS-AUDIOLOGY SERVICES (Biaural) 2 2.000000 100.0000 50.0000
AUDE-V5160-DISPENSING FEE BINAURAL 3 4.000000 920.0000 230.0000
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 4639 6540.500000 325482.7700 49.7642
COIFF-COIFFGT-IFSP CONSULT,PROF,FACE TO FACE 824 1022.500000 51100.0000 49.9756
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 1098 1148.250000 28668.7500 24.9673
CMS/EIP Fiscal Report Statewide
Services beginning 07/01/2019 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
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 4373 9640.500000 481478.7500 49.9433
CONIF-CONIFGT-CONSULT,ITDS,FACE TO FACE 1670 2339.750000 116937.5000 49.9786
CONIP-CONIP-CONSULT, ITDS PHONE 684 981.250000 24512.4500 24.9808
CONOF-CONOF-CONSULT, OT, FACE TO FACE 2453 3430.250000 171500.0000 49.9964
CONOF-CONOFGT-CONSULT,OT,FACE TO FACE 1003 882.750000 44100.5000 49.9581
CONOP-CONOP-CONSULT, OT, PHONE 295 651.250000 16218.7500 24.9040
CONPF-CONPF-CONSULT, PT, FACE TO FACE 1589 2265.500000 111762.5000 49.3324
CONPF-CONPFGT-CONSULT,PT,FACE TO FACE 606 530.750000 26537.5000 50.0000
CONPP-CONPP-CONSULT, PT, PHONE 160 87.250000 2175.0000 24.9284
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 3469 5242.250000 261737.5000 49.9285
CONSF-CONSFGT-CONSULT,SLP,FACE TO FACE 1217 1325.500000 66262.5000 49.9906
CONSP-CONSP-CONSULT, SLP, PHONE 469 592.500000 14787.5000 24.9578
COUN-H2019HR-INDIVIDUAL/FAMILY THERAPY 1 2.000000 146.6400 73.3200
DSTT-DSTT-DIRECT SERVICE COORDINATOR TRAVEL 4520 14814.25000 0.0000 0.0000
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 59 357.500000 8937.5000 25.0000
EIIF-96154-HEALTH AND BEHAVIOR INTERVENTION 1 50.750000 2537.5000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 5821 77539.77000 3842164.2600 49.5509
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 2013 12922.75000 644587.5000 49.8801
INTR-T1013-INTERPRETER 1298 5042.660000 252769.7400 50.1263
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 23103 403875.0000 4033326.6950 9.9866
OCCT-97530-OT SESSION BY LICENSED OT 883 7106.252633 494230.0300 69.5486
OCCT-97530GT-OT SESSION BY LICENSED OT 224 981.185890 68850.2500 70.1704
OCCT-97530HM-OT SESSION BY OT ASST 229 1982.711898 112525.8000 56.7535
OCCT-97530HMGT-OT SESSION BY OT ASST 35 125.909790 7202.0400 57.2000
PHY-97110-PT SESSION BY LICENSED PT 847 8380.027992 577808.1300 68.9506
PHY-97110GT-PT SESSION BY LICENSED PT 231 918.236282 64054.2200 69.7579
PHY-97110HM-PT SESSION BY PT ASST 50 399.490211 22137.6300 55.4147
PHY-97110HMGT-PT SESSION BY LICENSED PT ASST 6 10.322078 590.0100 57.1600
PHY-97110TLGT-PT SESSION BY LICENSED PT 1 1.500000 107.1600 71.4400
SENS-HA_INS-SENSORY AID INSURANCE PER EAR 1 1.000000 525.0000 525.0000
SENS-V5050-IN EAR MONAURAL HEARING AID 3 6.000000 1368.0000 228.0000
SENS-V5140-BEHIND EAR BINAURAL HEARING AID 1 1.000000 456.0000 456.0000
SENS-V5264-EARMOLD 7 20.000000 360.0000 18.0000
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 2028 20027.65366 1381293.1500 68.9693
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 526 2872.411954 201137.0800 70.0238
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 6 24.000000 844.9000 35.2042
SPL-92507TLGT-SPL THERAPY SESSION BY LICENSED SLP 3 4.500000 321.4800 71.4400
SPL-92508-GROUP SPL SESSION PER CHILD 13 27.000000 343.6400 12.7274
TELEC-TELEC-TELECONFERENCE,PROVIDER TO FAMILY,PHONE 1138 1884.250000 69717.2500 37.0000
TRAV-TRAVS-Travel by mile 11572 1858487.000 817435.7700 0.4398
Subtotal (Total Children Is Unduplicated) 29094 2454819.882 14412665.1450 5.8712
-----------------------------------------------------------------------------------------------------------------------
Total 2670953.168440 22039590.5975 8.2516
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 46094
-----------------------------------------------------------------------------------------------------------------------
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 63810 290706.750000 864948.1100 864549.6300
D 1780 8167.000000 25575.2500 0.0000
S 56 71.000000 1481.6400 0.0000
H 2 3.000000 171.4400 0.0000
T 3173 12491.250000 57584.7500 57609.7500
29385 18820.000000 663489.9300 0.0000
Other 21 34.000000 2413.5000 0.0000
---------------------------------------------------------
Total 98227 330293.000000 1615664.6200 922159.3800
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 15922 54345.250000 356573.1500 356328.5600
937 2908.750000 27372.7600 0.0000
Other 15859 51715.750000 271871.4400 0.0000
---------------------------------------------------------
Total 32718 108969.750000 655817.3500 356328.5600
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 23145 220409.250000 543923.0700 543923.0700
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 484 4277.500000 14401.4300 14401.4300
T 818 7229.500000 17240.1600 17240.1600
24712 34030.750000 613988.8400 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 49159 265947.000000 1189553.5000 575564.6600
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 13894 50507.500000 885180.9300 883433.9300
D 39 56.000000 2166.5000 0.0000
S 1 0.500000 18.5000 0.0000
H 59 193.000000 2490.0000 2390.0000
T 0 0.000000 0.0000 0.0000
15989 14364.500000 568309.8100 0.0000
Other 17 39.500000 1439.3400 1260.7400
---------------------------------------------------------
Total 29999 65161.000000 1459605.0800 887084.6700
Center 05
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 3 1.000000 37.0000 0.0000
P 27333 304884.250000 910477.5600 910499.5600
D 115 69.750000 2713.7500 0.0000
S 0 0.000000 0.0000 0.0000
H 1 0.500000 25.0000 25.0000
T 0 0.000000 0.0000 0.0000
12566 10277.000000 231853.4000 8297.4000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 40018 315232.500000 1145106.7100 918821.9600
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 52460 51628.000000 1100548.1600 1100548.1600
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
30373 17257.750000 568876.0900 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 82834 68886.500000 1669452.0000 1100548.1600
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 22819 66590.160000 1338443.3050 1338464.8100
D 404 288.750000 11813.7500 150.0000
S 0 0.000000 0.0000 0.0000
H 29 58.000000 4350.0000 0.0000
T 0 0.000000 0.0000 0.0000
30549 17220.650600 550460.2725 -10.0000
Other 1 2.000000 111.0000 0.0000
---------------------------------------------------------
Total 53802 84159.560600 1905178.3275 1338604.8100
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 59262 433521.500000 2619606.6700 2619606.6700
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
4829 22472.500000 251263.2100 9.2500
Other 17 30.500000 2184.5000 0.0000
---------------------------------------------------------
Total 64108 456024.500000 2873054.3800 2619615.9200
Center 10
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 9 6.750000 249.7500 0.0000
P 37609 106468.500000 2828278.3700 2828440.3700
D 130 132.250000 4838.8200 0.0000
S 224 285.500000 9099.2900 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
24521 18334.750000 592475.5000 0.0000
Other 530 934.500000 62628.7500 0.0000
---------------------------------------------------------
Total 63023 126162.250000 3497570.4800 2828440.3700
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 8110 38602.250000 589232.9500 589205.2000
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 0 0.000000 0.0000 0.0000
10951 7806.750000 270931.1600 397.2000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 19062 46409.250000 860173.3600 589602.4000
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 7 98.500000 145.9000 145.9000
D 0 0.000000 0.0000 0.0000
S 264 212.750000 7011.5000 0.0000
H 0 0.000000 0.0000 0.0000
T 18450 174781.250000 464832.2300 447732.5110
7514 5335.250000 165065.3400 494.3400
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 26235 180427.750000 637054.9700 448372.7510
Center 53
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 1 0.500000 18.5000 0.0000
P 4 2.250000 46.2500 27.7500
D 205 213.750000 9200.3300 0.0000
S 10 152.500000 103.3000 0.0000
H 0 0.000000 0.0000 0.0000
T 19564 148221.500000 248952.9700 248283.4700
42249 30940.750000 635466.1900 37.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 62033 179531.250000 893787.5400 248348.2200
Center 54
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 8 5.000000 219.4400 0.0000
P 4 1.500000 27.7500 83.2500
D 102 95.650000 5850.0700 0.0000
S 27 364.000000 701.7800 0.0000
H 0 0.000000 0.0000 0.0000
T 38997 235318.400000 482717.1600 481738.7800
48562 34793.500000 753287.9900 46.2500
Other 2 2.000000 142.8800 0.0000
---------------------------------------------------------
Total 87702 270580.050000 1242947.0700 481868.2800
Center 55
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 9.2500 0.0000
P 35240 63079.085562 657199.8601 657217.0800
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 4 5.750000 301.7500 0.0000
T 490 670.000000 7388.3100 7388.3100
22385 14615.722278 487669.0199 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 58121 78371.057840 1152568.1900 664605.3900
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 9 2.750000 101.7500 101.7500
D 14 11.000000 425.5000 370.0000
S 191 180.500000 6882.8700 6882.8700
H 0 0.000000 0.0000 0.0000
T 15809 80040.750000 709426.8900 709426.8900
16187 14559.750000 525096.0100 370.0400
Other 4 3.000000 124.0000 124.0000
---------------------------------------------------------
Total 32214 94797.750000 1242057.0200 717275.5500