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: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 9 6.500000 240.5000 37.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 118 348.500000 12811.2500 36.7611
Subtotal (Total Children Is Unduplicated) 122 355.000000 13051.7500 36.7655
-----------------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
AUDE-92552-PURE TONE AUDIOMETRY -AIR ONLY 72 78.000000 1471.3100 18.8629
AUDE-92553-PURE TONE AUDIOMETRY AIR & BONE 9 10.000000 204.7400 20.4740
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 102 111.000000 1572.0000 14.1622
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 94 101.000000 944.4400 9.3509
AUDE-92568-ACOUSTIC REFLEX TESTING (MEMR) 3 3.000000 29.8800 9.9600
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 111 121.000000 3323.0600 27.4633
AUDE-92582-CONDITIONED PLAY AUDIOMETRY 1 1.000000 38.4700 38.4700
AUDE-92585-AUD EVOKED RESPONSE (COMP) 3 3.000000 253.5500 84.5167
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 34 34.000000 538.6700 15.8432
AUDE-92588-OTOACOUSTIC EMISSIONS (COMP) 31 32.000000 666.3000 20.8219
AUDE-V5010-ASSESSMENT FOR HEARING AID 4 4.000000 180.0000 45.0000
AUDE-V5090-DISPENSING FEE PER HEARING AID 4 6.000000 690.0000 115.0000
EVAL-96111-DEVELOPMENTAL EVALUATION 12 19.750000 987.5000 50.0000
EXIT-EXIT-EXIT ASSESSMENT 14 16.500000 825.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 109 170.491733 12651.8799 74.2082
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 9 16.000000 1200.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 33 59.507866 4343.0900 72.9835
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 9 18.500000 1237.5000 66.8919
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 26 40.500000 2841.5000 70.1605
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 6 13.000000 825.0000 63.4615
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 76 139.500000 13148.1500 94.2520
IPDEF-T1024TLTSGT-F/U PHYC AND DEV EVAL BY EI PROF 13 24.500000 1837.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 132 232.500000 12822.7500 55.1516
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 11 20.000000 1110.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 2156 3799.494467 277203.4751 72.9580
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 384 732.159734 53985.6300 73.7348
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 789 1444.644535 104581.0603 72.3922
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 159 296.544666 21092.3200 71.1270
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 660 1055.592266 77649.4400 73.5601
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 145 271.500000 19822.5000 73.0110
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 2248 3863.290000 212422.1800 54.9848
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 392 709.500000 39001.8700 54.9709
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 1017 1641.247034 142524.9400 86.8394
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 148 274.000000 20550.0000 75.0000
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 10 10.000000 3040.0000 304.0000
MED-99204-OUTPATIENT VISIT, NEW, 45 MINS 2 2.000000 1014.0000 507.0000
OCTF-97168-OT RE-EVAL EST PLAN CARE 21 21.200196 1043.9300 49.2415
OCTH-97165-OT EVAL LOW COMPLEXITY 10 10.000000 398.4400 39.8440
OCTH-97166-OT EVAL MODERATE COMPLEXITY 55 60.000000 2844.4400 47.4073
OCTH-97166GT-OT EVAL MODERATE COMPLEXITY 4 5.000000 204.2000 40.8400
OCTH-97166TLGT-OT EVAL MODERATE COMPLEXITY 5 5.000000 255.2500 51.0500
OCTH-97167-OT EVAL HIGH COMPLEXITY 144 150.730656 7300.3600 48.4331
OCTH-97167GT-OT EVAL HIGH COMPLEXITY 7 8.000000 321.0300 40.1288
PSTF-97164-PT RE-EVAL EST PLAN CARE 23 23.000000 1056.9700 45.9552
PSTH-97161-PT EVAL LOW COMPLEXITY 6 6.000000 306.3000 51.0500
PSTH-97161GT-PT EVAL LOW COMPLEXITY 2 2.000000 102.1000 51.0500
PSTH-97162-PT EVAL MODERATE COMPLEXITY 29 32.000000 1461.7900 45.6809
PSTH-97162GT-PT EVAL MODERATE COMPLEXITY 4 4.000000 139.5900 34.8975
PSTH-97163-PT EVAL HIGH COMPLEXITY 77 83.000000 3988.4500 48.0536
PSTH-97163GT-PT EVAL HIGH COMPLEXITY 3 3.000000 143.1500 47.7167
SCREEN-T1023-SCREENING 67 72.000000 3400.0000 47.2222
SPCH-92521-EVAL OF SPEECH FLUENCY 4 5.000000 204.2000 40.8400
SPCH-92522-EVAL OF SPCH SOUND PROD 9 9.000000 418.9500 46.5500
SPCH-92522GT-EVAL OF SPCH SOUND PROD 2 2.000000 102.1000 51.0500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 292 310.490500 15641.0100 50.3752
SPCH-92523GT-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 24 26.000000 1209.8700 46.5335
SPCH-92524-BEHAV & QUAL ANALYSIS OF VOICE AND RES 38 42.000000 2083.2400 49.6010
SPCH-92524GT-BEHAV & QUAL ANALYSIS OF VOICE AND RES 5 8.000000 308.8300 38.6038
SPCH-92610-EVAL OF ORAL,PHARYNGEAL SWALLOWING FUNC 9 12.000000 437.5600 36.4633
SPCH-92610GT-EVAL OF ORAL,PHARYNGEAL SWALLOWING FUNC 1 1.000000 44.5500 44.5500
Subtotal (Total Children Is Unduplicated) 5231 16275.14365 1080046.0153 66.3617
-----------------------------------------------------------------------------------------------------------------------
EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 34 72.000000 22564.2800 313.3928
AUD-92592TS-AUDIOLOGY SERVICES (Monaural) 1 1.000000 50.0000 50.0000
AUD-92593TS-AUDIOLOGY SERVICES (Biaural) 3 3.000000 150.0000 50.0000
AUDE-V5160-DISPENSING FEE BINAURAL 5 5.000000 979.0000 195.8000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 43 45.000000 2250.0000 50.0000
CONIP-CONIP-CONSULT, ITDS PHONE 80 62.000000 1550.0000 25.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 2 2.000000 100.0000 50.0000
CONOF-CONOFGT-CONSULT,OT,FACE TO FACE 2 4.000000 200.0000 50.0000
CONOP-CONOP-CONSULT, OT, PHONE 11 10.000000 250.0000 25.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 42 43.000000 2150.0000 50.0000
CONSP-CONSP-CONSULT, SLP, PHONE 58 48.500000 1212.5000 25.0000
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:TPIN
Eligibility Filter:Program Patients
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
DSTT-DSTT-DIRECT SERVICE COORDINATOR TRAVEL 2 1.750000 0.0000 0.0000
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 5 7.000000 175.0000 25.0000
EIIF-96154-HEALTH AND BEHAVIOR INTERVENTION 1 2.000000 100.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 1969 25007.09000 1236684.0500 49.4533
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 724 4069.250000 203463.1600 50.0002
INTR-T1013-INTERPRETER 5 13.250000 518.7500 39.1509
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 13 29.000000 290.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 819 7642.790895 513440.4159 67.1797
OCCT-97530GT-OT SESSION BY LICENSED OT 220 1027.564110 70383.5000 68.4955
OCCT-97530HM-OT SESSION BY OT ASST 241 2251.226564 127580.8500 56.6717
OCCT-97530HMGT-OT SESSION BY OT ASST 45 175.090210 9986.5600 57.0367
OCCT-97530TLGT-OT SESSION BY LICENSED OT 9 30.000000 2143.2000 71.4400
PHY-97110-PT SESSION BY LICENSED PT 775 8162.238729 549326.4585 67.3010
PHY-97110GT-PT SESSION BY LICENSED PT 235 1173.590000 79571.4700 67.8018
PHY-97110HM-PT SESSION BY PT ASST 50 540.125784 30752.9600 56.9367
PHY-97110HMGT-PT SESSION BY LICENSED PT ASST 6 20.677923 1181.9500 57.1600
PHY-97110TLGT-PT SESSION BY LICENSED PT 2 2.750000 196.4600 71.4400
SENS-V5014-*HEARING AID REPAIR BY MANUFACTURER 1 2.000000 228.0000 114.0000
SENS-V5050-IN EAR MONAURAL HEARING AID 1 2.000000 1000.0000 500.0000
SENS-V5060-BEHIND EAR HEARING AID 1 1.000000 228.0000 228.0000
SENS-V5140-BEHIND EAR BINAURAL HEARING AID 3 3.000000 1368.0000 456.0000
SENS-V5264-EARMOLD 17 31.000000 544.0600 17.5503
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 1948 20165.52215 1381292.5491 68.4977
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 623 3078.708707 210249.8300 68.2916
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 21 57.750000 3303.3000 57.2000
SPL-92507TLGT-SPL THERAPY SESSION BY LICENSED SLP 4 22.000000 1571.6800 71.4400
SPL-92508-GROUP SPL SESSION PER CHILD 13 37.500000 635.6200 16.9499
TRAV-TRAVS-Travel by mile 7 233.000000 103.4400 0.4439
Subtotal (Total Children Is Unduplicated) 5110 74084.37507 4457775.0435 60.1716
-----------------------------------------------------------------------------------------------------------------------
Total 90714.518724 5550872.8088 61.1906
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 8226
-----------------------------------------------------------------------------------------------------------------------
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 10617 10676.000000 589090.5900 587037.1200
D 324 325.250000 19187.3500 20.0900
S 193 206.500000 13095.1400 0.0000
H 1735 1866.000000 124013.1700 0.0000
T 970 964.250000 57466.5300 56996.9100
925 978.250000 59512.0900 0.0000
Other 33 51.000000 3591.0000 0.0000
---------------------------------------------------------
Total 14797 15067.250000 865955.8700 644054.1200
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 1579 1364.250000 93514.5600 93421.2200
179 149.000000 11679.1500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 1758 1513.250000 105193.7100 93421.2200
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 509 503.000000 27852.4400 27852.4400
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 12 12.000000 -349.5000 -349.5000
T 17 17.000000 952.5900 952.5900
312 354.000000 23218.6100 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 850 886.000000 51674.1400 28455.5300
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 908 1697.000000 134281.7400 90565.2400
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 66 243.000000 12439.9500 0.0000
T 0 0.000000 0.0000 0.0000
175 180.000000 15994.3400 0.0000
Other 178 391.000000 26722.9600 908.3300
---------------------------------------------------------
Total 1327 2511.000000 189438.9900 91473.5700
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 747 1329.000000 85218.5600 85218.5600
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
21 44.250000 2776.7700 2776.7700
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 768 1373.250000 87995.3300 87995.3300
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 5698 3358.000000 220701.9400 220701.9400
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
3425 3135.750000 215487.8700 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 9123 6493.750000 436189.8100 220701.9400
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 2079 4597.608300 304830.2550 304686.6900
D 85 168.000000 12576.0500 0.0000
S 4 3.500000 142.5000 0.0000
H 25 49.000000 3651.0500 0.0000
T 0 0.000000 0.0000 0.0000
181 195.750000 9752.1000 27.8300
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 2374 5013.858300 330951.9550 304714.5200
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 2272 4140.250000 258277.2000 260238.0100
D 31 31.000000 1989.6400 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
653 1736.500000 121030.8200 0.0000
Other 140 229.500000 17056.5000 0.0000
---------------------------------------------------------
Total 3096 6137.250000 398354.1600 260238.0100
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 3248 2761.000000 159424.6000 159160.1000
D 5 5.000000 93.3800 0.0000
S 4 7.500000 535.8000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
3922 7076.750000 474851.8000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 7179 9850.250000 634905.5800 159160.1000
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 1114 3291.750000 221758.3500 221758.3500
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
88 231.000000 15560.5000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 1202 3522.750000 237318.8500 221758.3500
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 416 556.000000 37220.5300 25702.8800
D 9 10.000000 533.4900 462.0500
S 12 12.750000 609.5100 0.0000
H 167 217.500000 14823.4100 12.6600
T 3509 5542.500000 328308.8700 301726.4300
1387 2168.500000 121656.9800 105.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 5500 8507.250000 503152.7900 328009.0200
Center 53
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 83 57.000000 2109.0000 0.0000
P 151 131.610000 9014.4000 12247.6400
D 761 783.270000 46587.7960 0.0000
S 10 9.250000 652.2100 0.0000
H 0 0.000000 0.0000 0.0000
T 581 578.534306 30238.2100 29988.2100
2069 2237.725694 137646.2200 0.0000
Other 357 375.250000 24995.4500 0.0000
---------------------------------------------------------
Total 4012 4172.640000 251243.2860 42235.8500
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 167 127.002900 9160.6760 12536.9400
D 749 732.745708 51652.6600 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 1510 1639.270000 85946.9804 85646.9700
1699 1980.960000 112338.4740 65.8300
Other 172 181.500000 12971.1000 0.0000
---------------------------------------------------------
Total 4297 4661.478608 272069.8904 98249.7400
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 3684 3662.780722 239576.8400 239576.8400
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 55 87.000000 6131.8700 0.0000
T 44 43.500000 2609.9800 2609.9800
3104 2661.760894 168815.9574 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 6887 6455.041616 417134.6474 242186.8200
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 709 406.916200 26460.3800 26538.0300
D 0 0.000000 0.0000 0.0000
S 54 32.500000 2215.6500 2215.6500
H 16 21.500000 795.5000 0.0000
T 3621 11729.334000 591133.3900 591133.3900
1707 2359.250000 148688.8800 68767.1300
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 6107 14549.500200 769293.8000 688654.2000