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
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 11908 13958.25000 516268.7500 36.9866
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 8177 12849.25000 25.0000 0.0019
TCM-T1017TL-TARGETED CASE MANAGEMENT 21205 64661.00000 2390111.2500 36.9637
Subtotal (Total Children Is Unduplicated) 22413 91468.50000 2906405.0000 31.7749
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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) 22 22.000000 229.2400 10.4200
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 27 28.000000 245.0000 8.7500
AUDE-92568-ACOUSTIC REFLEX TESTING (MEMR) 2 2.000000 16.1200 8.0600
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 27 28.000000 611.5200 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 156 245.750000 30842.5000 125.5036
EXIT-EXIT-EXIT ASSESSMENT 648 1016.500000 50787.5000 49.9631
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 155 236.500000 17272.4100 73.0334
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 92 134.500000 10087.5000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 41 60.500000 4294.9100 70.9902
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 106 165.500000 12910.5500 78.0094
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 225 356.500000 19758.0000 55.4222
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 2158 3363.000100 249664.4800 74.2386
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 1081 1607.500000 119278.0200 74.2009
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 693 1032.500000 76980.0000 74.5569
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 2778 4255.000000 235566.0200 55.3622
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 1410 2166.000000 164870.1200 76.1173
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 71 71.000000 6355.9000 89.5197
MED-99204-OUTPATIENT VISIT, NEW, 45 MINS 5 5.000000 286.3500 57.2700
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 12 12.000000 684.5100 57.0425
NUTR-97803-NUTRITIONAL EVAL, FOLLOW-UP 32 109.000000 5450.0000 50.0000
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 7 7.000000 357.3500 51.0500
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 150 153.000000 7724.0300 50.4839
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 15 16.000000 811.8000 50.7375
PSTH-97001-EVAL BY LICENSED PT, INITIAL 35 39.000000 1780.2300 45.6469
SCREEN-T1023-SCREENING 132 162.000000 8054.8900 49.7215
SPCH-92521-EVAL OF SPEECH FLUENCY 5 5.000000 255.2500 51.0500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 208 212.000000 10932.3200 51.5675
SPCH-92524-BEHAV & QUAL ANALYSIS OF
VOICE AND RES 7 7.000000 357.3500 51.0500
Subtotal (Total Children Is Unduplicated) 5695 15589.75010 1039208.2000 66.6597
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 43 57.000000 11550.8500 202.6465
AUDE-V5160-DISPENSING FEE BINAURAL 1 1.000000 230.0000 230.0000
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 1035 1201.500000 60046.7500 49.9765
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 35 27.250000 681.2500 25.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 2008 3397.000000 169766.2500 49.9753
CONIP-CONIP-CONSULT, ITDS PHONE 144 177.750000 4443.7500 25.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 325 454.500000 22725.0000 50.0000
CONOP-CONOP-CONSULT, OT, PHONE 31 28.750000 718.7500 25.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 214 258.250000 12912.5000 50.0000
CONPP-CONPP-CONSULT, PT, PHONE 13 19.500000 487.5000 25.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 549 621.500000 31075.0000 50.0000
CONSP-CONSP-CONSULT, SLP, PHONE 44 83.750000 2093.7500 25.0000
COUN-H2019HR-INDIVIDUAL/FAMILY THERAPY 20 55.000000 4032.6000 73.3200
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 77 2858.500000 71462.5000 25.0000
EIIF-96154-HEALTH AND BEHAVIOR INTERVENTION 8 246.500000 11605.0000 47.0791
EIIF-EIIF_NM-EI INDIVIDUAL SESSION BY NONMED PROF 13 53.500000 2675.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 7972 51322.25000 2564070.8300 49.9602
INTR-T1013-INTERPRETER 428 1368.750000 66972.0000 48.9293
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 13170 98469.00000 986357.9700 10.0169
OCCT-97530-OT SESSION BY LICENSED OT 997 4808.251100 338014.7300 70.2989
OCCT-97530HM-OT SESSION BY OT ASST 272 1304.516259 74105.9300 56.8072
PHY-97110-PT SESSION BY LICENSED PT 959 4908.550612 347081.1600 70.7095
PHY-97110HM-PT SESSION BY PT ASST 159 845.435969 48029.0000 56.8097
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 2351 14049.71216 998370.9540 71.0599
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 44 66.000000 3758.1800 56.9421
SPL-92508-GROUP SPL SESSION PER CHILD 17 55.000000 763.4000 13.8800
TRAV-TRAVS-Travel by mile 5073 434339.0000 192874.6400 0.4441
Subtotal (Total Children Is Unduplicated) 14668 621091.7161 6028690.8440 9.7066
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Total 728149.966202 9974304.0440 13.6981
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Number of Children (Unduplicated) With at Least One Service 24256
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Center 01
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 46 20.500000 758.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 8067 5400.250000 200337.2700 0.2500
P 3250 14306.750000 52208.2600 52176.6800
D 207 826.500000 7035.4300 385.1200
S 769 839.000000 41972.9300 60.0000
H 49 63.000000 4628.8000 0.0000
T 12803 55509.750000 241877.2100 237694.3700
6612 4807.500000 144765.8000 94.5400
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 31803 81773.250000 693584.2000 290410.9600
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 3658 11116.750000 94540.9000 82742.0000
929 2285.500000 29099.9000 0.0000
Other 4889 7006.000000 98015.5700 0.0000
---------------------------------------------------------
Total 9476 20408.250000 221656.3700 82742.0000
Center 03
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 219 151.250000 7116.6900 0.0000
P 3901 2506.250000 104487.0000 35805.7500
D 45 28.000000 1042.5000 0.0000
S 0 0.000000 0.0000 0.0000
H 177 173.750000 43548.6900 0.0000
T 0 0.000000 0.0000 0.0000
12118 44569.250000 218519.6200 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 16460 47428.500000 374714.5000 35805.7500
Center 04
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 1 2.000000 74.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 845 1204.000000 48563.0000 0.0000
P 5347 13249.000000 316927.0300 317060.6400
D 36 59.500000 2201.5000 0.0000
S 1 2.000000 74.0000 0.0000
H 2008 7288.500000 361177.7300 1941.4400
T 0 0.000000 0.0000 0.0000
3831 6137.250000 225423.0800 0.0000
Other 83 203.500000 12081.8900 3009.2300
---------------------------------------------------------
Total 12152 28145.750000 966522.2300 322011.3100
Center 05
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 2587 1827.000000 76518.2500 0.0000
P 3825 50599.000000 126594.6340 126621.5750
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
2853 2544.500000 57459.7500 953.2200
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 9265 54970.500000 260572.6340 127574.7950
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 7072 6695.750000 158573.2300 158573.2300
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
16269 11136.750000 372608.9500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 23341 17832.500000 531182.1800 158573.2300
Center 07
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 7 3.750000 138.7500 0.0000
U 0 0.000000 0.0000 0.0000
B 362 253.250000 9568.7500 0.0000
P 8383 12613.750000 344988.1900 344960.4400
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
6466 3981.500000 118461.6900 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 15218 16852.250000 473157.3800 344960.4400
Center 09
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 2 4.000000 261.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 237 225.500000 8889.1300 12.5000
P 19318 107711.000000 836184.8500 835149.8600
D 2 2.000000 142.8800 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 4050 56056.250000 237017.5000 237017.5000
6583 10215.750000 518901.3800 2048.7900
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 30192 174214.500000 1601396.7400 1074228.6500
Center 10
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 1345 1092.750000 52386.5000 0.0000
P 10505 22145.250000 613548.2300 613548.2300
D 30 25.250000 1048.2500 0.0000
S 1 0.500000 18.5000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
5581 10047.000000 485092.1400 0.0000
Other 1 0.250000 9.2500 0.0000
---------------------------------------------------------
Total 17463 33311.000000 1152102.8700 613548.2300
Center 51
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 1 1.000000 75.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 2926 1815.500000 69836.0000 0.0000
P 2088 6733.000000 215529.8200 215510.8400
D 10 4.500000 166.5000 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
6206 5841.000000 263307.9800 70.0000
Other 2 2.500000 187.5000 0.0000
---------------------------------------------------------
Total 11233 14397.500000 549102.8000 215580.8400
Center 52
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 12 21.500000 1555.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 2409 2363.500000 99719.5000 0.0000
P 641 773.500000 45277.9400 41078.7800
D 3 4.000000 253.8800 0.0000
S 12 52.500000 951.4300 501.4300
H 0 0.000000 0.0000 0.0000
T 5726 58165.000000 210031.5300 204615.0100
4629 4706.250000 206868.5200 1414.9200
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 13432 66086.250000 564658.3000 247610.1400
Center 53
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 3 4.250000 194.2500 0.0000
U 0 0.000000 0.0000 0.0000
B 1975 1860.750000 85741.7900 0.0000
P 2057 1940.000000 86268.7500 86218.7500
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 2004 13227.750000 23720.8300 23720.8300
T 1 1.000000 37.0000 0.0000
17159 32682.250000 323080.9700 0.0000
Other 10 10.000000 100.0000 0.0000
---------------------------------------------------------
Total 23209 49726.000000 519143.5900 109939.5800
Center 54
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 2 2.000000 100.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 5484 4547.750000 190091.0000 0.0000
P 751 792.750000 42368.5000 42418.3000
D 0 0.000000 0.0000 0.0000
S 21 21.500000 1187.5000 0.0000
H 3881 23194.250000 52899.1500 52899.1500
T 2 2.000000 340.4000 303.4000
19434 39945.250000 344063.5900 0.0000
Other 2 1.750000 64.7500 0.0000
---------------------------------------------------------
Total 29577 68507.250000 631114.8900 95620.8500
Center 55
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 166 131.000000 4847.0000 4070.0000
P 8380 9467.394540 248359.7200 249421.7600
D 1 2.000000 150.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 22 44.000000 3300.0000 0.0000
T 0 0.000000 0.0000 0.0000
10063 9052.071662 394786.1800 52324.1300
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 18632 18696.466202 651442.9000 305815.8900
Center 57
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 3605 3589.000000 143617.2500 0.0000
P 12 11.280000 717.0400 270.0400
D 13 17.500000 704.0000 0.0000
S 117 379.000000 7945.2400 7945.2400
H 0 0.000000 0.0000 0.0000
T 3574 23890.720000 263509.4000 263509.4000
4668 7854.500000 365333.5200 254321.3600
Other 38 58.000000 2126.0100 2126.0100
---------------------------------------------------------
Total 12027 35800.000000 783952.4600 528172.0500