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
Payclass Filters:GR
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 10037 13281.75000 490709.7500 36.9462
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 6732 13419.50000 1082.2500 0.0806
TCM-T1017TL-TARGETED CASE MANAGEMENT 5978 16793.75000 615206.0000 36.6330
Subtotal (Total Children Is Unduplicated) 14950 43495.00000 1106998.0000 25.4512
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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) 12 12.000000 125.0400 10.4200
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 21 21.000000 183.7500 8.7500
AUDE-92568-ACOUSTIC REFLEX TESTING (MEMR) 3 3.000000 24.1800 8.0600
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 22 22.000000 480.4800 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 92 113.500000 5650.0000 49.7797
EXIT-EXIT-EXIT ASSESSMENT 553 901.250000 44812.5000 49.7226
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 26 32.000000 2400.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 18 21.000000 1575.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 3 2.000000 150.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 10 13.000000 975.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 45 48.000000 2663.0000 55.4792
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 354 489.529667 35727.2100 72.9827
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 88 134.803866 9894.6700 73.4005
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 111 138.266667 10261.2500 74.2135
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 538 809.000000 44666.7500 55.2123
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 254 361.500000 27075.0000 74.8963
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 42 42.000000 1701.0000 40.5000
MED-99204-OUTPATIENT VISIT, NEW, 45 MINS 3 3.000000 171.8100 57.2700
MED-99205-OUTPATIENT VISIT, NEW, 60 MINS 2 2.000000 113.2800 56.6400
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 9 9.000000 199.2600 22.1400
NUTR-97803-NUTRITIONAL EVAL, FOLLOW-UP 9 33.000000 1650.0000 50.0000
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 4 4.000000 178.2100 44.5525
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 73 75.000000 3730.1000 49.7347
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 7 7.000000 357.3500 51.0500
PSTH-97001-EVAL BY LICENSED PT, INITIAL 27 27.000000 1291.9400 47.8496
SCREEN-T1023-SCREENING 6 6.000000 300.0000 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 111 113.000000 5686.2800 50.3211
SPCH-92524-BEHAV & QUAL ANALYSIS OF
VOICE AND RES 6 6.000000 306.3000 51.0500
Subtotal (Total Children Is Unduplicated) 1780 3514.850200 205267.9400 58.4002
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 26 37.000000 22885.9000 618.5378
AUDE-V5160-DISPENSING FEE BINAURAL 1 1.000000 230.0000 230.0000
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 1051 1171.000000 55964.6900 47.7922
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 39 32.250000 806.2500 25.0000
CONIF-CONIF-CONSULT, FACE TO FACE 2236 4439.500000 221156.2500 49.8156
CONIP-CONIP-CONSULT, PHONE 156 231.750000 5640.7500 24.3398
COUN-H2019HR-INDIVIDUAL/FAMILY THERAPY 3 11.000000 806.5200 73.3200
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 16 70.250000 1756.2500 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 2326 15371.50000 762968.1000 49.6352
INTR-T1013-INTERPRETER 193 789.500000 32988.3200 41.7838
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 11196 90858.50000 908608.0800 10.0003
OCCT-97530-OT SESSION BY LICENSED OT 473 2583.948966 178714.9200 69.1635
OCCT-97530HM-OT SESSION BY OT ASST 88 545.003118 30996.3200 56.8737
PHY-97110-PT SESSION BY LICENSED PT 541 2920.945975 194615.4187 66.6275
PHY-97110HM-PT SESSION BY PT ASST 35 175.400100 9761.0500 55.6502
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 1567 9886.937473 658043.3200 66.5568
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 7 9.500000 543.4000 57.2000
SPL-92508-GROUP SPL SESSION PER CHILD 14 247.000000 3425.6400 13.8690
TRAV-TRAVS-Travel by mile 4034 358613.4700 158543.4650 0.4421
Subtotal (Total Children Is Unduplicated) 12285 488285.9556 3263648.7637 6.6839
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Total 535295.805832 4575914.7037 8.5484
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Number of Children (Unduplicated) With at Least One Service 18631
-----------------------------------------------------------------------------------------------------------------------
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 40 88.000000 1134.9800 1134.9800
D 3 4.000000 210.0000 0.0000
S 127 129.250000 4526.0900 0.0000
H 0 0.000000 0.0000 0.0000
T 117 148.000000 2427.1800 2307.1800
4668 3031.250000 81482.8000 0.0000
Other 2882 4613.500000 67731.5000 0.0000
---------------------------------------------------------
Total 7837 8014.000000 157512.5500 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 1013 4169.500000 29294.2000 5154.4250
2592 10533.500000 86440.1300 30.0000
Other 2586 6886.250000 44336.3100 0.0000
---------------------------------------------------------
Total 6191 21589.250000 160070.6400 5184.4250
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 0 0.000000 0.0000 0.0000
D 24 19.500000 914.4400 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
10724 40698.750000 204080.2400 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 10748 40718.250000 204994.6800 0.0000
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 3092 10784.750000 190789.9800 190789.9800
D 28 43.250000 1656.7500 0.0000
S 0 0.000000 0.0000 0.0000
H 4 6.500000 421.4800 321.4800
T 0 0.000000 0.0000 0.0000
2802 2705.000000 107798.0500 0.0000
Other 7 13.500000 715.8000 322.8800
---------------------------------------------------------
Total 5933 13553.000000 301382.0600 191434.3400
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 3061 50757.750000 121498.6450 102630.7500
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
2360 1690.500000 38215.4800 37.7400
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 5421 52448.250000 159714.1250 102668.4900
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
7073 3784.500000 113020.5700 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 16319 12524.250000 312705.8000 199685.2300
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 3197 12511.000000 202618.6100 202618.6100
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
4869 3793.750000 102051.0350 543.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 8068 16308.750000 304969.6450 203161.6100
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 19937 124205.250000 837946.5400 837946.0400
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
279 847.750000 16996.1600 662.8900
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 20216 125053.000000 854942.7000 838608.9300
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 7266 21547.250000 494607.8300 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
4051 2796.750000 83995.5000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 11317 24344.000000 578603.3300 494607.8300
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 2053 6841.250000 199262.6000 199262.5400
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
4394 3559.000000 92532.1300 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 6447 10400.250000 291794.7300 199262.5400
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 1 0.750000 53.5800 53.5800
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 4557 43722.750000 169702.2550 165619.0200
2748 6018.250000 37882.5200 155.3200
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 7315 49756.750000 208115.5450 166305.1100
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 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
8417 22457.250000 106442.9600 0.0000
Other 127 121.250000 2557.5000 0.0000
---------------------------------------------------------
Total 14877 47072.250000 186626.9500 77626.4900
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 0 0.000000 0.0000 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 6366 25780.600520 81230.0899 81230.0850
6908 21780.000000 89617.7600 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 20272 74934.110520 264296.4887 174573.2850
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 7442 10258.262512 186996.7600 187033.7900
D 40 41.500000 1535.5000 0.0000
S 2 2.500000 92.5000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
2804 1680.182800 57372.3600 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 10288 11982.445312 245997.1200 187033.7900
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 0 0.000000 0.0000 0.0000
D 0 0.000000 0.0000 0.0000
S 166 557.000000 8803.7900 8813.7900
H 0 0.000000 0.0000 0.0000
T 3491 23683.250000 241954.6700 243065.4800
2657 2351.000000 93185.5600 1471.5600
Other 2 6.000000 244.3200 244.3200
---------------------------------------------------------
Total 6316 26597.250000 344188.3400 253595.1500