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: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 10919 14320.50000 529051.0000 36.9436
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 7384 14443.25000 1218.2500 0.0843
TCM-T1017TL-TARGETED CASE MANAGEMENT 19708 57527.25000 2116966.5000 36.7994
Subtotal (Total Children Is Unduplicated) 20975 86291.00000 2647235.7500 30.6780
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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 173 256.500000 27200.0000 106.0429
EXIT-EXIT-EXIT ASSESSMENT 555 904.250000 44962.5000 49.7235
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 102 185.500000 13912.5000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 67 100.000000 7500.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 24 24.500000 1837.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 72 115.000000 9277.5000 80.6739
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 153 239.500000 13291.2500 55.4958
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 2098 3297.729403 245053.3802 74.3097
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 750 1167.500400 87003.5700 74.5212
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 671 942.000000 70503.7500 74.8447
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 2475 3981.500000 220383.7300 55.3519
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 1418 2149.000000 165630.0000 77.0731
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 81 81.000000 7544.0000 93.1358
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 53 53.000000 2650.0000 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 181 187.000000 9451.2100 50.5412
SPCH-92524-BEHAV & QUAL ANALYSIS OF
VOICE AND RES 10 10.000000 510.5000 51.0500
Subtotal (Total Children Is Unduplicated) 5143 14134.97980 946768.0802 66.9805
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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 2286 4550.000000 226681.2500 49.8201
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 6955 50766.00000 2532199.1000 49.8798
INTR-T1013-INTERPRETER 211 822.750000 34715.8200 42.1949
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 11412 91313.50000 913158.5400 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 2282 14810.25230 1018084.0396 68.7418
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 4295 391948.2700 173177.9050 0.4418
Subtotal (Total Children Is Unduplicated) 12991 569549.0240 5854541.4203 10.2793
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Total 669975.003774 9448545.2505 14.1028
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Number of Children (Unduplicated) With at Least One Service 22597
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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 6709 4557.000000 174415.3700 0.0000
P 41 88.250000 1144.2300 1144.2300
D 4 4.250000 219.2500 0.0000
S 296 277.250000 10348.0900 0.0000
H 34 48.500000 3605.3800 0.0000
T 117 148.000000 2427.1800 2307.1800
5107 3345.750000 91315.8400 0.0000
Other 2949 4907.250000 71712.9200 0.0000
---------------------------------------------------------
Total 15265 13379.250000 355306.7000 3451.4100
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 1133 4623.500000 37023.2500 5162.4350
2740 11803.250000 100110.0200 30.0000
Other 4071 8087.250000 89352.5200 0.0000
---------------------------------------------------------
Total 7944 24514.000000 226485.7900 5192.4350
Center 03
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 31 12.500000 475.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 181 197.750000 12338.3300 111.0000
P 2692 1675.500000 67714.5000 67795.2420
D 24 19.500000 914.4400 0.0000
S 0 0.000000 0.0000 0.0000
H 338 334.500000 55643.9700 0.0000
T 0 0.000000 0.0000 0.0000
11387 41228.750000 230666.2300 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 14653 43468.500000 367752.9700 67906.2420
Center 04
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 54 67.000000 2479.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 581 793.750000 30122.7500 0.0000
P 5161 13553.250000 308830.0300 306627.9300
D 29 47.750000 1823.2500 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
3568 3829.750000 160482.9600 43.1800
Other 46 116.750000 7685.8700 874.0100
---------------------------------------------------------
Total 11553 25931.750000 890477.3000 307866.6000
Center 05
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 2552 1632.250000 67555.2500 0.0000
P 3071 50894.750000 121732.9000 102853.8800
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
2599 1965.000000 44608.8150 37.7400
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 8222 54492.000000 233896.9650 102891.6200
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 9249 8745.750000 200036.2300 200036.2300
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
12408 7458.750000 273255.8800 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 21657 16204.500000 473292.1100 200036.2300
Center 07
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 28 18.000000 666.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 71 47.250000 1828.0000 0.0000
P 7851 16133.750000 350042.5000 349911.5000
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
5456 4426.750000 121064.2450 543.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 13408 20629.750000 473900.7450 350454.5000
Center 09
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 5 5.000000 198.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 190 226.500000 12625.9400 225.2500
P 26788 156669.250000 1140332.1200 1251368.8700
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 2 3.000000 162.5000 37.5000
2476 9044.500000 355462.0200 866.1100
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 29462 165949.500000 1508826.8300 1252543.9800
Center 10
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 270 175.250000 6484.2500 0.0000
U 0 0.000000 0.0000 0.0000
B 6579 5135.000000 228799.2500 0.0000
P 7272 21560.750000 494796.3300 494777.8300
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
7505 12456.000000 598563.0700 10.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 21626 39327.000000 1328642.9000 494787.8300
Center 51
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 14 10.750000 415.2500 0.0000
U 0 0.000000 0.0000 0.0000
B 2583 1681.750000 63177.7500 0.0000
P 2076 6865.250000 200039.0400 200038.9800
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
5575 6548.250000 267501.1500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 10253 15108.250000 531216.4400 200038.9800
Center 52
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 28 52.500000 3918.5000 1050.0000
U 0 0.000000 0.0000 0.0000
B 1826 1802.500000 89044.2500 15060.0000
P 911 772.000000 28335.7800 28333.2800
D 0 0.000000 0.0000 0.0000
S 11 19.000000 662.4800 512.4800
H 0 0.000000 0.0000 0.0000
T 4916 45145.500000 191209.7850 179582.2800
4192 8108.250000 153276.0100 155.3200
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 11884 55899.750000 466446.8050 224693.3600
Center 53
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 1 0.500000 18.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 1845 1741.750000 72330.5000 0.0000
P 1726 1715.250000 80961.5000 81026.2500
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 1583 9828.000000 19566.5600 19566.5600
T 4973 15342.000000 61575.7600 61575.7600
12070 26247.750000 275444.8100 111.0000
Other 127 121.250000 2557.5000 0.0000
---------------------------------------------------------
Total 22325 54996.500000 512455.1300 162279.5700
Center 54
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 4796 4202.250000 184439.2500 0.0000
P 1 2.000000 74.0000 0.0000
D 3 5.500000 203.5000 0.0000
S 0 0.000000 0.0000 0.0000
H 7157 27644.460000 95372.9088 95378.4700
T 6559 26245.700520 84360.0399 84273.0350
10710 25665.609480 271543.4112 0.0000
Other 1 0.750000 27.7500 0.0000
---------------------------------------------------------
Total 29227 83766.270000 636020.8599 179651.5050
Center 55
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 1 1.000000 37.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 171 162.750000 6021.7500 18.5000
P 9583 12360.217249 274125.6202 292024.1500
D 44 43.000000 1591.0000 0.0000
S 54 31.000000 1147.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
6716 5016.516525 271096.8554 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 16569 17614.483774 554019.2256 292042.6500
Center 57
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 6 6.750000 249.7500 0.0000
U 0 0.000000 0.0000 0.0000
B 3493 3410.250000 136462.2500 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 3520 24338.250000 243460.6300 244571.4400
5397 10243.000000 495293.5000 393528.0000
Other 71 107.000000 3862.2700 3923.7100
---------------------------------------------------------
Total 12678 38693.500000 889804.4800 651142.4800