CMS/EIP Fiscal Report Statewide
Services beginning 01/01/2016 ending 03/31/2016 Date of Report:05/12/2016 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 12193 14926.00000 551929.5000 36.9777
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 8487 18606.00000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 21480 66997.25000 2472799.5000 36.9090
Subtotal (Total Children Is Unduplicated) 22627 100529.2500 3024729.0000 30.0880
-----------------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
ASTE-ASTE-ASSISTIVE TECHNOLOGY EVAL 18 20.000000 970.0000 48.5000
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 2 2.000000 20.8400 10.4200
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 4 4.000000 35.0000 8.7500
AUDE-92568-ACOUSTIC REFLEX TESTING (MEMR) 1 1.000000 8.0600 8.0600
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 7 7.000000 152.8800 21.8400
AUDE-92585-AUD EVOKED RESPONSE (COMP) 1 1.000000 65.1400 65.1400
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 5 5.000000 114.5000 22.9000
AUDE-92588-OTOACOUSTIC EMISSIONS (COMP) 1 1.000000 25.5300 25.5300
BEHV-BEHV-BEHAVIORAL ASSESSMENT 5 5.000000 625.0000 125.0000
EVAL-96111-DEVELOPMENTAL EVALUATION 222 353.000000 33845.0000 95.8782
EXIT-EXIT-EXIT ASSESSMENT 583 937.750000 46808.9400 49.9162
IPDEF-IPDEF_NM-F/U PSYCH & DEV EVAL BY NON-MED PROF 1 2.000000 111.0000 55.5000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 107 197.500000 14533.8700 73.5892
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 70 127.000000 9525.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 34 54.000000 3622.5000 67.0833
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 67 101.000000 7556.2500 74.8144
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 175 303.000000 16566.7500 54.6757
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 2230 3495.500697 257855.3197 73.7678
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 722 1131.000200 82222.6400 72.6990
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 662 949.500300 70606.7700 74.3620
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 2892 4495.500000 248226.7500 55.2167
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 1523 2346.499997 175252.0197 74.6866
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 77 77.000000 4699.5000 61.0325
MED-99204-OUTPATIENT VISIT, NEW, 45 MINS 4 4.000000 229.0800 57.2700
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 12 12.000000 436.5400 36.3783
NUTR-97803-NUTRITIONAL EVAL, FOLLOW-UP 16 85.000000 4250.0000 50.0000
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 10 11.000000 561.5500 51.0500
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 125 130.000000 6405.0200 49.2694
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 17 17.000000 867.8500 51.0500
PSTH-97001-EVAL BY LICENSED PT, INITIAL 64 66.000000 3379.4700 51.2041
SCREEN-T1023-SCREENING 102 123.000000 6150.0000 50.0000
SPCH-92521-EVAL OF SPEECH FLUENCY 2 2.000000 102.1000 51.0500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 185 189.000000 9609.0700 50.8416
SPCH-92524-BEHAV & QUAL ANALYSIS OF
VOICE AND RES 21 22.000000 1123.1000 51.0500
Subtotal (Total Children Is Unduplicated) 5627 15277.25119 1006563.0394 65.8864
-----------------------------------------------------------------------------------------------------------------------
EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 37 53.000000 23862.2200 450.2306
AUD-92593TS-AUDIOLOGY SERVICES (Biaural) 1 1.000000 50.0000 50.0000
AUDE-V5160-DISPENSING FEE BINAURAL 1 1.000000 239.2000 239.2000
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 1287 1449.250000 72316.2500 49.8991
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 59 41.500000 1037.5000 25.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 2285 4830.000000 241250.0000 49.9482
CONIP-CONIP-CONSULT, ITDS PHONE 193 283.000000 7075.0000 25.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 92 96.500000 4825.0000 50.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 41 40.500000 2025.0000 50.0000
CONPP-CONPP-CONSULT, PT, PHONE 6 7.000000 175.0000 25.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 176 171.500000 8575.0000 50.0000
CONSP-CONSP-CONSULT, SLP, PHONE 12 13.000000 325.0000 25.0000
COUN-H2019HR-INDIVIDUAL/FAMILY THERAPY 2 2.000000 146.6400 73.3200
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 113 6058.750000 151468.7500 25.0000
EIIF-96154-HEALTH AND BEHAVIOR INTERVENTION 5 110.000000 5500.0000 50.0000
EIIF-EIIF_NM-EI INDIVIDUAL SESSION BY NONMED PROF 18 76.750000 3837.5000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 7205 52601.75000 2627841.7200 49.9573
INTR-T1013-INTERPRETER 422 1499.750000 71060.7900 47.3818
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 12300 112070.0000 1020770.0100 9.1083
OCCT-97530-OT SESSION BY LICENSED OT 885 4861.750000 344771.7300 70.9151
OCCT-97530HM-OT SESSION BY OT ASST 224 868.249999 49634.4200 57.1660
PHY-97110-PT SESSION BY LICENSED PT 982 5725.772500 408673.5000 71.3744
PHY-97110HM-PT SESSION BY PT ASST 159 787.250100 44553.2700 56.5935
SENS-V5140-BEHIND THE EAR BINAURAL HEARING AID
1 1.000000 474.2000 474.2000
SENS-V5264-EARMOLD 2 3.000000 54.0000 18.0000
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 2466 16020.96060 1141408.0700 71.2447
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 93 224.000000 12812.8000 57.2000
SPL-92508-GROUP SPL SESSION PER CHILD 26 70.250000 1021.1500 14.5359
TRAV-TRAVS-Travel by mile 4647 427290.0000 189358.8000 0.4432
Subtotal (Total Children Is Unduplicated) 13794 635258.4832 6435142.5200 10.1300
-----------------------------------------------------------------------------------------------------------------------
Total 751064.984393 10466434.5594 13.9355
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 23876
-----------------------------------------------------------------------------------------------------------------------
Center 01
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 16 6.500000 231.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 8200 5316.750000 195930.6900 9.2500
P 6811 12647.250000 147462.7800 147462.7800
D 11 10.500000 601.8300 0.0000
S 329 281.750000 10538.3700 240.0000
H 0 0.000000 0.0000 0.0000
T 2784 6874.250000 62645.0500 63649.7600
7747 8455.250000 145262.5400 287.0800
Other 15 12.500000 600.2600 0.0000
---------------------------------------------------------
Total 25913 33604.750000 563273.0200 211648.8700
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 1 1.000000 10.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 3787 12679.250000 116652.5400 85605.1200
509 530.750000 20183.8000 121.4400
Other 5396 10245.500000 119047.6300 40.0000
---------------------------------------------------------
Total 9693 23456.500000 255893.9700 85766.5600
Center 03
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 4 3.500000 213.5500 0.0000
U 0 0.000000 0.0000 0.0000
B 1751 1128.000000 44831.7500 0.0000
P 2540 1651.750000 69453.5000 69822.8360
D 42 15.250000 564.2500 0.0000
S 0 0.000000 0.0000 0.0000
H 386 384.250000 68014.5300 0.0000
T 0 0.000000 0.0000 0.0000
17516 72358.500000 341398.6000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 22239 75541.250000 524476.1800 69822.8360
Center 04
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 160 218.500000 9205.5000 0.0000
P 6371 15713.250000 368827.3800 369749.1700
D 46 66.250000 2451.2500 0.0000
S 2 4.250000 157.2500 0.0000
H 2350 8160.000000 409433.6800 281.4400
T 0 0.000000 0.0000 0.0000
3805 9108.750000 304834.0700 0.0000
Other 56 124.000000 7874.0900 1055.1400
---------------------------------------------------------
Total 12790 33395.000000 1102783.2200 371085.7500
Center 05
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 3 1.500000 55.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 2140 1390.500000 56690.5000 0.0000
P 3619 57231.000000 147482.0100 147450.4350
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
2915 2272.750000 61395.0600 451.3000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 8677 60895.750000 265623.0700 147901.7350
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 6331 5986.000000 134000.6900 134000.6900
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
17074 21565.750000 385694.0800 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 23405 27551.750000 519694.7700 134000.6900
Center 07
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 2 1.000000 37.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 9 5.500000 203.5000 64.7500
P 9958 17151.000000 385104.6700 385086.1700
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
6605 4463.250000 136278.7800 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 16574 21620.750000 521623.9500 385150.9200
Center 09
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 1 2.750000 101.7500 0.0000
U 0 0.000000 0.0000 0.0000
B 98 109.750000 5588.0000 58.5000
P 26619 159481.750000 1175317.6900 1434409.4600
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
2333 10769.500000 354606.0300 881.9900
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 29051 170363.750000 1535613.4700 1435349.9500
Center 10
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 16 12.250000 453.2500 0.0000
U 0 0.000000 0.0000 0.0000
B 4770 3903.250000 181288.2500 0.0000
P 10893 26161.750000 648883.2500 648843.2500
D 6 2.250000 83.2500 18.5000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
8571 14309.000000 689809.5700 511.8600
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 24256 44388.500000 1520517.5700 649373.6100
Center 51
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 18 12.750000 471.7500 0.0000
U 0 0.000000 0.0000 0.0000
B 2944 1957.250000 74936.7500 0.0000
P 2114 6506.250000 211442.8600 211442.8600
D 25 14.000000 518.0000 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
6711 6234.750000 279153.3000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 11812 14725.000000 566522.6600 211442.8600
Center 52
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 5 10.000000 750.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 2184 2022.250000 94874.0000 35.0000
P 875 787.750000 31132.0000 30827.0200
D 30 9.750000 395.1900 0.0000
S 159 206.500000 9578.3700 6346.3100
H 0 0.000000 0.0000 0.0000
T 5222 53273.500000 182607.3800 178048.3400
4789 9549.500000 188866.3500 57.5700
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 13264 65859.250000 508203.2900 215314.2400
Center 53
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 152 114.250000 4374.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 2240 2067.250000 89376.7500 111.0000
P 2054 2002.750000 93589.7500 93534.2500
D 0 0.000000 0.0000 0.0000
S 6 10.000000 551.7500 0.0000
H 1943 10442.950000 24410.8500 24410.8500
T 2147 13525.250000 24171.9700 24171.9700
13747 13835.800000 261520.1700 0.0000
Other 101 95.250000 2065.0000 0.0000
---------------------------------------------------------
Total 22390 42093.500000 500060.2400 142228.0700
Center 54
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 2 2.000000 74.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 5484 4709.750000 202608.5500 0.0000
P 118 120.750000 6270.5000 6270.5000
D 1 1.000000 37.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 4917 28983.390000 74985.7900 74985.7900
T 3100 17525.752222 44259.0900 44249.0900
18207 32043.377778 350368.4500 0.0000
Other 2 3.000000 111.0000 0.0000
---------------------------------------------------------
Total 31831 83389.020000 678714.3800 125505.3800
Center 55
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 14 12.500000 538.5000 0.0000
P 11092 14216.402173 331776.1300 331709.3800
D 36 51.000000 2951.0000 0.0000
S 2 2.250000 83.2500 0.0000
H 23 44.000000 3300.0000 0.0000
T 0 0.000000 0.0000 0.0000
7624 5875.562220 313740.1194 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 18791 20201.714393 652388.9994 331709.3800
Center 57
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 3987 3884.000000 157210.7500 111.0000
P 0 0.000000 0.0000 0.0000
D 8 8.000000 352.5000 0.0000
S 204 924.500000 8685.7800 8685.7800
H 1 1.000000 75.0000 0.0000
T 2921 20879.750000 196105.0000 206228.0000
4896 8221.000000 386795.8200 281272.5700
Other 35 60.250000 1820.9200 1820.9200
---------------------------------------------------------
Total 12052 33978.500000 751045.7700 498118.2700