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
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 12191 14916.00000 551559.5000 36.9777
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 8486 18592.75000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 7231 21671.50000 798203.2500 36.8319
Subtotal (Total Children Is Unduplicated) 17884 55180.25000 1349762.7500 24.4610
-----------------------------------------------------------------------------------------------------------------------
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 6 6.000000 131.0400 21.8400
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 150 226.000000 10425.0000 46.1283
EXIT-EXIT-EXIT ASSESSMENT 582 936.250000 46733.9400 49.9161
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 26 32.000000 2218.2400 69.3200
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 29 33.000000 2475.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 5 6.500000 332.7900 51.1985
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 16 22.000000 1631.2500 74.1477
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 56 65.500000 3487.6200 53.2461
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 563 841.084796 60695.4197 72.1633
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 141 223.106100 15184.0200 68.0574
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 169 234.766222 17169.4100 73.1341
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 916 1231.500000 67502.4200 54.8132
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 389 585.518930 43428.4397 74.1709
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 50 50.000000 2025.0000 40.5000
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 9 9.000000 199.2600 22.1400
NUTR-97803-NUTRITIONAL EVAL, FOLLOW-UP 12 33.000000 1650.0000 50.0000
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 7 8.000000 408.4000 51.0500
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 74 75.000000 3648.3200 48.6443
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 4 3.552800 181.3700 51.0499
PSTH-97001-EVAL BY LICENSED PT, INITIAL 33 34.000000 1641.9000 48.2912
SCREEN-T1023-SCREENING 26 42.000000 2100.0000 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 128 130.118511 6603.1700 50.7474
SPCH-92524-BEHAV & QUAL ANALYSIS OF
VOICE AND RES 11 10.910000 556.5500 51.0128
Subtotal (Total Children Is Unduplicated) 2442 4880.807359 292440.5894 59.9164
-----------------------------------------------------------------------------------------------------------------------
EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 34 47.000000 22794.6300 484.9921
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 1260 1412.750000 70491.2500 49.8965
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 50 34.000000 850.0000 25.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 2260 4767.500000 238125.0000 49.9476
CONIP-CONIP-CONSULT, ITDS PHONE 182 245.250000 6131.2500 25.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 91 95.500000 4775.0000 50.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 41 40.000000 2000.0000 50.0000
CONPP-CONPP-CONSULT, PT, PHONE 6 7.000000 175.0000 25.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 173 168.500000 8425.0000 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 20 69.750000 1743.7500 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 2499 17042.45000 850821.9600 49.9237
INTR-T1013-INTERPRETER 422 1499.750000 71060.7900 47.3818
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 12295 112026.0000 1020330.0100 9.1080
OCCT-97530-OT SESSION BY LICENSED OT 527 2770.920534 194999.2700 70.3735
OCCT-97530HM-OT SESSION BY OT ASST 81 383.874472 21928.2200 57.1234
PHY-97110-PT SESSION BY LICENSED PT 595 3216.082081 218901.8200 68.0647
PHY-97110HM-PT SESSION BY PT ASST 50 259.660977 14616.0000 56.2888
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 1697 10552.39157 740647.9800 70.1877
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 3 18.500000 1058.2000 57.2000
SPL-92508-GROUP SPL SESSION PER CHILD 8 30.500000 423.3400 13.8800
TRAV-TRAVS-Travel by mile 4575 406154.0000 179989.8000 0.4432
Subtotal (Total Children Is Unduplicated) 13345 561049.1296 3680914.8100 6.5608
-----------------------------------------------------------------------------------------------------------------------
Total 621110.186988 5323118.1494 8.5703
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 21436
-----------------------------------------------------------------------------------------------------------------------
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 6784 12620.250000 146004.5400 146004.5400
D 9 8.750000 537.0800 0.0000
S 23 22.000000 927.6200 240.0000
H 0 0.000000 0.0000 0.0000
T 2780 6870.250000 62423.6100 63428.3200
7734 8448.500000 145012.7900 287.0800
Other 4 4.000000 285.7600 0.0000
---------------------------------------------------------
Total 17334 27973.750000 355191.4000 209959.9400
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 3763 12655.250000 115013.0000 84777.8900
429 448.750000 14832.5200 121.4400
Other 3572 8867.750000 63022.6300 40.0000
---------------------------------------------------------
Total 7765 21972.750000 192878.1500 84939.3300
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 1.000000 0.0000 50.0000
D 42 15.250000 564.2500 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
17494 72340.500000 339620.3800 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 17537 72356.750000 340184.6300 50.0000
Center 04
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 1 4.000000 148.0000 0.0000
P 3312 11248.000000 194465.3000 194465.3000
D 45 65.500000 2423.5000 0.0000
S 0 0.000000 0.0000 0.0000
H 29 41.000000 471.4400 281.4400
T 0 0.000000 0.0000 0.0000
3033 2895.000000 116581.3100 0.0000
Other 9 15.000000 470.0000 410.0000
---------------------------------------------------------
Total 6429 14268.500000 314559.5500 195156.7400
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 3617 57229.000000 147359.5200 147327.9450
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
2866 2201.750000 56157.1200 451.3000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 6483 59430.750000 203516.6400 147779.2450
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
11425 17517.000000 209932.7700 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 17756 23503.000000 343933.4600 134000.6900
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 4340 12859.250000 210218.9200 210218.9200
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
6478 4278.250000 127040.2500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 10818 17137.500000 337259.1700 210218.9200
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 20847 135355.000000 887389.2000 887416.2800
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
251 2046.750000 15141.5200 581.4500
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 21098 137401.750000 902530.7200 887997.7300
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 7989 24219.250000 576924.8000 576924.8000
D 5 1.750000 64.7500 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
5148 3726.750000 116969.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 13142 27947.750000 693958.5500 576924.8000
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 2114 6506.250000 211442.8600 211442.8600
D 8 3.500000 129.5000 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
5741 3568.750000 117110.3600 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 7863 10078.500000 328682.7200 211442.8600
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 2 4.000000 111.9400 111.9400
D 0 0.000000 0.0000 0.0000
S 158 206.250000 9569.1200 6346.3100
H 0 0.000000 0.0000 0.0000
T 5211 53118.000000 182294.3500 177735.3100
3319 7211.750000 45166.7700 57.5700
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 8690 60540.000000 237142.1800 184251.1300
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 1 1.250000 0.0000 0.0000
H 1943 10442.950000 24410.8500 24410.8500
T 2147 13525.250000 24171.9700 24171.9700
11637 11572.750000 144449.4000 0.0000
Other 101 95.250000 2065.0000 0.0000
---------------------------------------------------------
Total 15829 35637.450000 195097.2200 48582.8200
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 0 0.000000 0.0000 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
14745 28570.890000 174913.5500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 22762 75080.032222 294158.4300 119234.8800
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 7807 10860.402173 188795.1300 188795.1300
D 36 51.000000 2951.0000 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
3715 2422.052593 84562.9194 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 11558 13333.454766 276309.0494 188795.1300
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 8 8.000000 352.5000 0.0000
S 204 924.500000 8685.7800 8685.7800
H 0 0.000000 0.0000 0.0000
T 2917 20868.750000 195568.0000 205728.0000
3031 2647.000000 103110.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 6160 24448.250000 307716.2800 214413.7800