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: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 10912 14309.00000 528625.5000 36.9436
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 7375 14386.00000 1193.2500 0.0829
TCM-T1017TL-TARGETED CASE MANAGEMENT 6530 18650.25000 683887.2500 36.6691
Subtotal (Total Children Is Unduplicated) 16258 47345.25000 1213706.0000 25.6352
-----------------------------------------------------------------------------------------------------------------------
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 118 159.500000 7950.0000 49.8433
EXIT-EXIT-EXIT ASSESSMENT 553 901.250000 44812.5000 49.7226
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 27 34.000000 2550.0000 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 4 3.000000 225.0000 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 46 48.500000 2690.7500 55.4794
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 482 680.705904 49786.9702 73.1402
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 125 185.663466 13540.8200 72.9321
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 157 198.766667 14761.2500 74.2642
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 705 1051.000000 58022.0400 55.2065
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 350 500.000000 37425.0000 74.8500
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 46 46.000000 1863.0000 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 7 7.000000 350.0000 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 114 116.000000 5839.4300 50.3399
SPCH-92524-BEHAV & QUAL ANALYSIS OF
VOICE AND RES 7 7.000000 357.3500 51.0500
Subtotal (Total Children Is Unduplicated) 2112 4256.386037 254148.0902 59.7098
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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 2238 4441.250000 221243.7500 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 2327 15372.50000 763018.1000 49.6353
INTR-T1013-INTERPRETER 211 822.750000 34715.8200 42.1949
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 11405 91240.50000 912428.5400 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 4192 363602.2700 160763.6450 0.4421
Subtotal (Total Children Is Unduplicated) 12579 493692.7556 3271554.4037 6.6267
-----------------------------------------------------------------------------------------------------------------------
Total 545294.391669 4739408.4939 8.6915
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Number of Children (Unduplicated) With at Least One Service 20014
-----------------------------------------------------------------------------------------------------------------------
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
5005 3289.750000 89123.3000 0.0000
Other 2908 4859.500000 68954.6700 0.0000
---------------------------------------------------------
Total 8200 8518.500000 166376.2200 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 1030 4514.500000 30088.4000 5162.4350
2633 11649.500000 88180.5200 30.0000
Other 2801 7076.000000 48068.2700 0.0000
---------------------------------------------------------
Total 6464 23240.000000 166337.1900 5192.4350
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 1 0.250000 9.2500 9.2500
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
11340 41203.250000 228466.5400 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 11365 41223.000000 229390.2300 9.2500
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 29 47.750000 1823.2500 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
3036 3015.250000 120276.9000 0.0000
Other 7 13.500000 715.8000 322.8800
---------------------------------------------------------
Total 6168 13867.750000 314027.4100 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 3070 50892.750000 121632.9000 102753.8800
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
2579 1938.250000 42731.8150 37.7400
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 5649 52831.000000 164364.7150 102791.6200
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
7348 3936.500000 118094.5700 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 16597 12682.250000 318130.8000 200036.2300
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 3238 12588.500000 203809.7500 203809.7500
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
5396 4325.000000 115610.2850 543.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 8636 16917.500000 319720.0350 204352.7500
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 20513 124806.250000 862176.9700 862176.4700
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 1 2.000000 112.5000 37.5000
287 858.750000 17821.1600 662.8900
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 20801 125667.000000 880110.6300 862876.8600
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 7271 21560.250000 494777.8300 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
4385 3102.250000 94154.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 11656 24662.500000 588931.8300 494777.8300
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 2075 6864.250000 199967.6000 199967.5400
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
4601 3708.250000 97240.3800 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 6676 10572.500000 297207.9800 199967.5400
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 10 17.000000 512.4800 512.4800
H 0 0.000000 0.0000 0.0000
T 4643 44850.500000 171525.0450 167392.4700
3005 6276.500000 42584.5300 155.3200
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 7659 51144.750000 214675.6350 168113.8500
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 1583 9828.000000 19566.5600 19566.5600
T 4973 15342.000000 61575.7600 61575.7600
8844 22963.000000 112704.6400 0.0000
Other 127 121.250000 2557.5000 0.0000
---------------------------------------------------------
Total 15527 48254.250000 196404.4600 81142.3200
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 3 5.500000 203.5000 0.0000
S 0 0.000000 0.0000 0.0000
H 7157 27644.460000 95372.9088 95378.4700
T 6557 26243.700520 84273.0399 84273.0350
7146 22089.750000 92870.3100 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 20863 75983.410520 272719.7587 179651.5050
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 7457 10282.967249 188641.3702 188678.4000
D 42 42.500000 1572.5000 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
3306 2020.763900 69631.6900 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 10807 12348.731149 259938.0602 188678.4000
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 3514 24330.250000 242974.8700 244085.6800
2785 2488.000000 99050.5600 1471.5600
Other 2 6.000000 244.3200 244.3200
---------------------------------------------------------
Total 6467 27381.250000 351073.5400 254615.3500