CMS/EIP Fiscal Report Statewide
Services beginning 10/01/2015 ending 12/31/2015 Date of Report:02/13/2016 Page: 1
List order: No List
Eligibility Filter:Part C (excluding not eligible)
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
CASE-CASE-NON-TCM CASE MANAGEMENT 10044 13292.00000 491089.0000 36.9462
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 6741 13475.50000 1107.2500 0.0822
TCM-T1017TL-TARGETED CASE MANAGEMENT 18134 52173.25000 1919432.7500 36.7896
Subtotal (Total Children Is Unduplicated) 19351 78940.75000 2411629.0000 30.5499
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Screening, Eval, and Assessment,Class #02
ASTE-ASTE-ASSISTIVE TECHNOLOGY EVAL 27 31.000000 1503.5000 48.5000
AUDE-92552-PURE TONE AUDIOMETRY -AIR ONLY 11 11.000000 164.2300 14.9300
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 14 14.000000 145.8800 10.4200
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 22 23.000000 201.2500 8.7500
AUDE-92568-ACOUSTIC REFLEX TESTING (MEMR) 3 3.000000 24.1800 8.0600
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 23 23.000000 502.3200 21.8400
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 10 10.000000 229.0000 22.9000
AUDE-V5010-ASSESSMENT FOR HEARING AID 1 1.000000 46.8000 46.8000
AUDE-V5090-DISPENSING FEE PER HEARING AID 2 3.000000 358.8000 119.6000
BEHV-BEHV-BEHAVIORAL ASSESSMENT 2 2.000000 250.0000 125.0000
EVAL-96111-DEVELOPMENTAL EVALUATION 121 164.500000 15700.0000 95.4407
EXIT-EXIT-EXIT ASSESSMENT 555 904.250000 44962.5000 49.7235
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 93 169.500000 12712.5000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 60 93.000000 6975.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 20 20.000000 1500.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 68 108.500000 8790.0000 81.0138
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 139 218.500000 12125.7500 55.4954
IPDEI-IPDEI_NM-INITIAL PSYCH & DEV EVAL BY NON-MED PR 1 2.000000 111.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 1594 2511.728700 186480.3800 74.2438
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 587 933.500400 69621.8900 74.5815
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 491 681.500000 51003.7500 74.8404
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 1873 3040.500000 168373.4800 55.3769
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 1056 1594.500000 123017.5000 77.1511
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 70 70.000000 6092.5000 87.0357
MED-99204-OUTPATIENT VISIT, NEW, 45 MINS 8 8.000000 907.8900 113.4863
MED-99205-OUTPATIENT VISIT, NEW, 60 MINS 2 2.000000 113.2800 56.6400
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 15 15.000000 589.9600 39.3307
NUTR-97803-NUTRITIONAL EVAL, FOLLOW-UP 13 68.000000 3400.0000 50.0000
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 6 6.000000 280.3100 46.7183
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 126 133.000000 6677.5500 50.2071
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 16 17.000000 867.8500 51.0500
PSTH-97001-EVAL BY LICENSED PT, INITIAL 58 63.000000 3427.6400 54.4070
SCREEN-T1023-SCREENING 47 47.000000 2350.0000 50.0000
SPCH-92521-EVAL OF SPEECH FLUENCY 3 3.000000 153.1500 51.0500
SPCH-92522-EVAL OF SPCH SOUND PROD 2 3.000000 102.1000 34.0333
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 178 183.000000 9247.0100 50.5301
SPCH-92524-BEHAV & QUAL ANALYSIS OF
VOICE AND RES 9 9.000000 459.4500 51.0500
Subtotal (Total Children Is Unduplicated) 4118 11189.97910 739468.4000 66.0831
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 26 40.000000 24363.7200 609.0930
AUD-92633-AUD REHAB POSTLING HEARING LOSS 1 2.000000 143.2200 71.6100
AUDE-V5160-DISPENSING FEE BINAURAL 1 1.000000 230.0000 230.0000
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 1068 1200.250000 57427.1900 47.8460
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 44 36.750000 918.7500 25.0000
CONIF-CONIF-CONSULT, FACE TO FACE 2284 4548.250000 226593.7500 49.8200
CONIP-CONIP-CONSULT, PHONE 157 254.750000 6215.7500 24.3994
COUN-H2019HR-INDIVIDUAL/FAMILY THERAPY 3 11.000000 806.5200 73.3200
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 58 1167.250000 29181.2500 25.0000
EIIF-96154-HEALTH AND BEHAVIOR INTERVENTION 2 190.000000 9450.0000 49.7368
EIIF-EIIF_NM-EI INDIVIDUAL SESSION BY NONMED PROF 16 88.500000 4425.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 6951 50747.00000 2531249.1000 49.8798
INTR-T1013-INTERPRETER 193 789.500000 32988.3200 41.7838
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 11203 90931.50000 909338.0800 10.0003
OCCT-97530-OT SESSION BY LICENSED OT 836 4502.000600 317091.8400 70.4335
OCCT-97530HM-OT SESSION BY OT ASST 225 1183.250400 67504.0600 57.0497
PHY-97110-PT SESSION BY LICENSED PT 951 5368.500671 376369.3057 70.1070
PHY-97110HM-PT SESSION BY PT ASST 133 611.250000 34674.2300 56.7268
SENS-HA_INS-SENSORY AID INSURANCE PER EAR 1 2.000000 500.0000 250.0000
SENS-V5050-IN EAR MONAURAL HEARING AID 1 1.000000 237.1200 237.1200
SENS-V5140-BEHIND THE EAR BINAURAL HEARING AID
1 2.000000 456.0000 228.0000
SENS-V5264-EARMOLD 4 7.000000 126.0000 18.0000
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 2280 14807.25230 1017869.7196 68.7413
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 101 395.000000 22594.0000 57.2000
SPL-92508-GROUP SPL SESSION PER CHILD 22 274.750000 3810.8100 13.8701
TRAV-TRAVS-Travel by mile 4137 386959.4700 170957.7250 0.4418
Subtotal (Total Children Is Unduplicated) 12696 564121.2240 5845521.4603 10.3622
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Total 654251.953071 8996618.8603 13.7510
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Number of Children (Unduplicated) With at Least One Service 20949
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Center 01
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 8 3.000000 118.4400 0.0000
U 0 0.000000 0.0000 0.0000
B 6411 4320.750000 165477.6200 0.0000
P 40 88.000000 1134.9800 1134.9800
D 4 4.250000 219.2500 0.0000
S 289 272.500000 10058.3400 0.0000
H 28 39.500000 2930.3800 0.0000
T 117 148.000000 2427.1800 2307.1800
4765 3084.750000 83582.8400 0.0000
Other 2918 4655.750000 70184.5000 0.0000
---------------------------------------------------------
Total 14580 12616.500000 336133.5300 3442.1600
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 1110 4266.500000 35368.0500 5154.4250
2690 10670.250000 97133.6300 30.0000
Other 3783 7824.750000 82762.3100 0.0000
---------------------------------------------------------
Total 7583 22761.500000 215263.9900 5184.4250
Center 03
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 30 11.750000 447.7500 0.0000
U 0 0.000000 0.0000 0.0000
B 140 144.000000 8593.3300 74.0000
P 2372 1391.750000 55470.7500 55626.9920
D 24 19.500000 914.4400 0.0000
S 0 0.000000 0.0000 0.0000
H 293 289.500000 46643.9700 0.0000
T 0 0.000000 0.0000 0.0000
10755 40718.250000 205894.9300 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 13614 42574.750000 317965.1700 55700.9920
Center 04
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 53 66.750000 2469.7500 0.0000
U 0 0.000000 0.0000 0.0000
B 557 746.750000 28346.2500 0.0000
P 5057 13400.750000 300569.2800 298744.6400
D 28 43.250000 1656.7500 0.0000
S 0 0.000000 0.0000 0.0000
H 2114 7523.500000 379053.4400 321.4800
T 0 0.000000 0.0000 0.0000
3275 3469.500000 144503.1100 43.1800
Other 46 116.750000 7685.8700 874.0100
---------------------------------------------------------
Total 11130 25367.250000 864284.4500 299983.3100
Center 05
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 2389 1488.000000 61002.0000 0.0000
P 3062 50759.750000 121598.6450 102730.7500
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
2376 1711.750000 39679.9800 37.7400
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 7827 53959.500000 222280.6250 102768.4900
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 9246 8739.750000 199685.2300 199685.2300
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
11883 7100.250000 257925.6300 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 21129 15840.000000 457610.8600 199685.2300
Center 07
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 28 18.000000 666.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 70 45.750000 1772.5000 0.0000
P 7387 15600.000000 327706.6100 327575.6100
D 0 0.000000 0.0000 0.0000
S 2 4.000000 300.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
4927 3891.500000 107204.9950 543.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 12414 19559.250000 437650.1050 328118.6100
Center 09
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 5 5.000000 198.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 162 185.750000 10037.6900 225.2500
P 25860 155534.250000 1088563.9400 1199563.1900
D 0 0.000000 0.0000 0.0000
S 1 1.250000 46.2500 46.2500
H 0 0.000000 0.0000 0.0000
T 1 1.000000 50.0000 0.0000
2435 8989.500000 351337.0200 866.1100
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 28464 164716.750000 1450232.9000 1200700.8000
Center 10
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 260 166.750000 6169.7500 0.0000
U 0 0.000000 0.0000 0.0000
B 5981 4512.750000 198000.7500 0.0000
P 7267 21547.750000 494626.3300 494607.8300
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
7077 11960.750000 575917.3200 10.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 20585 38188.000000 1274714.1500 494617.8300
Center 51
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 14 10.750000 415.2500 0.0000
U 0 0.000000 0.0000 0.0000
B 2486 1608.750000 60430.5000 0.0000
P 2054 6842.250000 199334.0400 199333.9800
D 5 2.250000 83.2500 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
5356 6385.500000 261807.0200 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 9915 14849.500000 522070.0600 199333.9800
Center 52
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 22 40.500000 3018.5000 830.0000
U 0 0.000000 0.0000 0.0000
B 1647 1580.000000 78091.7500 13382.5000
P 803 668.250000 24516.3200 24513.8200
D 0 0.000000 0.0000 0.0000
S 9 15.000000 477.1900 477.1900
H 0 0.000000 0.0000 0.0000
T 4814 43986.750000 187325.2450 176042.5600
3896 7782.000000 144132.0400 155.3200
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 11191 54072.500000 437561.0450 215401.3900
Center 53
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 1 0.500000 18.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 1696 1575.000000 65186.0000 0.0000
P 1575 1553.000000 73303.0000 73367.7500
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 1543 9338.500000 18887.0900 18887.0900
T 4790 15155.250000 58739.4000 58739.4000
11521 25575.500000 260537.1300 111.0000
Other 127 121.250000 2557.5000 0.0000
---------------------------------------------------------
Total 21253 53319.000000 479228.6200 151105.2400
Center 54
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 4400 3788.750000 165578.7500 0.0000
P 1 2.000000 74.0000 0.0000
D 2 3.000000 111.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 6996 27370.510000 93337.6388 93343.2000
T 6368 25782.600520 81317.0899 81230.0850
10354 25220.609480 260981.6112 0.0000
Other 1 0.750000 27.7500 0.0000
---------------------------------------------------------
Total 28122 82168.220000 601427.8399 174573.2850
Center 55
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 1 1.000000 37.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 149 134.750000 4985.7500 18.5000
P 9148 11812.762512 249453.2600 267361.5400
D 42 42.000000 1554.0000 0.0000
S 31 19.000000 703.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
6141 4539.970559 249560.2754 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 15512 16549.483071 506293.2854 267380.0400
Center 57
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 6 6.750000 249.7500 0.0000
U 0 0.000000 0.0000 0.0000
B 3323 3232.500000 128838.2500 0.0000
P 1 1.500000 55.5000 55.5000
D 8 7.750000 343.2500 0.0000
S 167 560.500000 9053.8300 9063.8300
H 15 18.500000 1023.5000 0.0000
T 3497 23691.250000 242440.4300 243551.2400
5255 10084.000000 488035.4500 392132.9500
Other 71 107.000000 3862.2700 3923.7100
---------------------------------------------------------
Total 12343 37709.750000 873902.2300 648727.2300