CMS/EIP Fiscal Report Statewide
Services beginning 07/01/2016 ending 09/30/2016 Date of Report:10/31/2016 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 11187 13229.75000 489349.2500 36.9885
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 7504 11857.50000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 6483 19211.50000 709982.5000 36.9561
Subtotal (Total Children Is Unduplicated) 16344 44298.75000 1199331.7500 27.0737
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Screening, Eval, and Assessment,Class #02
ASTE-ASTE-ASSISTIVE TECHNOLOGY EVAL 18 19.000000 921.5000 48.5000
AUDE-92552-PURE TONE AUDIOMETRY -AIR ONLY 21 21.000000 313.5300 14.9300
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 21 21.000000 218.8200 10.4200
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 26 27.000000 236.2500 8.7500
AUDE-92568-ACOUSTIC REFLEX TESTING (MEMR) 2 2.000000 16.1200 8.0600
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 26 27.000000 589.6800 21.8400
AUDE-92585-AUD EVOKED RESPONSE (COMP) 1 1.000000 65.1400 65.1400
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 17 17.000000 389.3000 22.9000
AUDE-92588-OTOACOUSTIC EMISSIONS (COMP) 2 2.000000 51.0600 25.5300
AUDE-V5010-ASSESSMENT FOR HEARING AID 5 6.000000 280.8000 46.8000
AUDE-V5090-DISPENSING FEE PER HEARING AID 4 5.000000 598.0000 119.6000
BEHV-BEHV-BEHAVIORAL ASSESSMENT 1 1.000000 125.0000 125.0000
EVAL-96111-DEVELOPMENTAL EVALUATION 92 118.000000 5875.0000 49.7881
EXIT-EXIT-EXIT ASSESSMENT 646 1012.500000 50587.5000 49.9630
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 39 46.500000 3022.4100 64.9981
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 29 30.500000 2287.5000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 12 15.500000 919.9100 59.3490
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 21 25.000000 1835.0000 73.4000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 54 62.500000 3468.7500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 371 527.271767 38536.5500 73.0867
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 152 231.846533 16695.1400 72.0094
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 129 188.500000 13913.9900 73.8143
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 580 749.500000 41483.2700 55.3479
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 299 428.009333 31561.8400 73.7410
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 10 10.000000 405.0000 40.5000
MED-99204-OUTPATIENT VISIT, NEW, 45 MINS 2 2.000000 114.5400 57.2700
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 4 4.000000 88.5600 22.1400
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 2 2.000000 102.1000 51.0500
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 89 90.000000 4533.9300 50.3770
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 8 9.000000 454.4500 50.4944
PSTH-97001-EVAL BY LICENSED PT, INITIAL 23 25.020568 1079.3200 43.1373
SCREEN-T1023-SCREENING 38 59.000000 2950.0000 50.0000
SPCH-92521-EVAL OF SPEECH FLUENCY 5 5.000000 255.2500 51.0500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 140 143.000000 7260.9200 50.7757
SPCH-92524-BEHAV & QUAL ANALYSIS OF
VOICE AND RES 5 5.000000 255.2500 51.0500
Subtotal (Total Children Is Unduplicated) 2053 3938.648201 231491.3800 58.7743
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 43 56.518000 11298.4700 199.9092
AUDE-V5160-DISPENSING FEE BINAURAL 1 1.000000 230.0000 230.0000
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 989 1139.000000 56921.7500 49.9752
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 26 18.750000 468.7500 25.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 1949 3262.000000 163016.2500 49.9743
CONIP-CONIP-CONSULT, ITDS PHONE 125 112.000000 2800.0000 25.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 316 444.500000 22225.0000 50.0000
CONOP-CONOP-CONSULT, OT, PHONE 31 28.750000 718.7500 25.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 187 211.750000 10587.5000 50.0000
CONPP-CONPP-CONSULT, PT, PHONE 10 7.500000 187.5000 25.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 516 581.000000 29050.0000 50.0000
CONSP-CONSP-CONSULT, SLP, PHONE 36 50.750000 1268.7500 25.0000
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 25 69.750000 1743.7500 25.0000
EIIF-96154-HEALTH AND BEHAVIOR INTERVENTION 8 246.500000 11605.0000 47.0791
EIIF-EIIF_NM-EI INDIVIDUAL SESSION BY NONMED PROF 11 40.500000 2025.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 2745 16399.50000 818154.8300 49.8890
INTR-T1013-INTERPRETER 397 1316.000000 64253.5000 48.8248
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 12944 98010.00000 981737.9700 10.0167
OCCT-97530-OT SESSION BY LICENSED OT 613 2711.900801 188931.7200 69.6676
OCCT-97530HM-OT SESSION BY OT ASST 136 648.481143 36769.5500 56.7010
PHY-97110-PT SESSION BY LICENSED PT 591 2464.801215 169153.0900 68.6275
PHY-97110HM-PT SESSION BY PT ASST 79 442.012773 24969.3300 56.4901
SENS-V5050-IN EAR MONAURAL HEARING AID 4 5.000000 1185.6000 237.1200
SENS-V5140-BEHIND THE EAR BINAURAL HEARING AID
1 1.000000 456.0000 456.0000
SENS-V5264-EARMOLD 5 8.000000 144.0000 18.0000
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 1566 8171.579988 572385.6540 70.0459
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 14 31.000000 1756.1800 56.6510
SPL-92508-GROUP SPL SESSION PER CHILD 13 49.000000 680.1200 13.8800
TRAV-TRAVS-Travel by mile 4683 370263.0000 164531.8400 0.4444
Subtotal (Total Children Is Unduplicated) 13963 506791.5439 3339255.8540 6.5890
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Total 555028.942121 4770078.9840 8.5943
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Number of Children (Unduplicated) With at Least One Service 20679
-----------------------------------------------------------------------------------------------------------------------
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 3227 14222.250000 51609.3100 51577.7300
D 192 810.500000 6192.5100 385.1200
S 117 191.250000 5400.3400 60.0000
H 0 0.000000 0.0000 0.0000
T 12725 54623.250000 237663.4500 233824.5400
6117 4332.750000 124333.9200 94.5400
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 22378 74180.000000 425199.5300 285941.9300
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 3605 10208.500000 92216.7400 81250.7400
871 1957.500000 26235.1100 0.0000
Other 2828 5556.500000 42177.9800 0.0000
---------------------------------------------------------
Total 7304 17722.500000 160629.8300 81250.7400
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 44 26.000000 968.5000 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
11637 44186.750000 203091.1800 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 11681 44212.750000 204059.6800 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 2627 9304.250000 155275.4400 155275.4400
D 34 56.500000 2090.5000 0.0000
S 0 0.000000 0.0000 0.0000
H 49 167.000000 1721.8900 1731.4400
T 0 0.000000 0.0000 0.0000
2831 2523.000000 103950.8600 0.0000
Other 35 90.000000 4329.9400 1779.3400
---------------------------------------------------------
Total 5576 12140.750000 267368.6300 158786.2200
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 3785 50252.500000 125532.0540 125558.9950
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
2592 2186.000000 51257.4300 917.5000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 6377 52438.500000 176789.4840 126476.4950
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 7070 6691.750000 158326.2300 158326.2300
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
11029 7182.500000 198710.9500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 18099 13874.250000 357037.1800 158326.2300
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 2998 8366.750000 170681.6900 170681.6900
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
5883 3478.000000 102630.5000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 8881 11844.750000 273312.1900 170681.6900
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 12415 72528.750000 490955.4000 490955.4000
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 2488 23406.250000 115530.0400 115530.0400
3757 2914.000000 103731.1600 1449.7900
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 18660 98849.000000 710216.6000 607935.2300
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 6308 18985.000000 471260.4800 471260.4800
D 30 25.250000 1048.2500 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
2812 1905.500000 53589.2500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 9150 20915.750000 525897.9800 471260.4800
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 6720.000000 215133.7700 215114.7900
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
5167 3145.250000 103990.0500 70.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 7242 9865.250000 319123.8200 215184.7900
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 0 0.000000 0.0000 0.0000
D 0 0.000000 0.0000 0.0000
S 9 46.500000 501.4300 501.4300
H 0 0.000000 0.0000 0.0000
T 5614 57011.750000 207040.9800 201695.7300
2834 1811.500000 40292.4200 157.1000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 8457 58869.750000 247834.8300 202354.2600
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 1993 13181.750000 23633.4600 23633.4600
T 0 0.000000 0.0000 0.0000
13987 29179.509333 171972.0700 0.0000
Other 9 9.000000 90.0000 0.0000
---------------------------------------------------------
Total 15989 42370.259333 195695.5300 23633.4600
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 3840 22876.000000 52346.1800 52346.1800
T 1 1.000000 303.4000 303.4000
16322 36533.500000 199725.9600 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 20163 59410.500000 252375.5400 52649.5800
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 5834 6874.871740 141167.2600 141167.2600
D 1 2.000000 150.0000 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
5625 4962.591048 137484.4500 47739.1600
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 11460 11839.462788 278801.7100 188906.4200
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 13 17.500000 704.0000 0.0000
S 113 371.000000 7545.2400 7545.2400
H 0 0.000000 0.0000 0.0000
T 3557 23437.720000 262669.0500 262669.0500
2946 2669.250000 104818.1600 50.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 6629 26495.470000 375736.4500 270264.2900