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: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 11904 13956.75000 516213.2500 36.9866
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 8164 12775.75000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 7001 20996.75000 775962.7500 36.9563
Subtotal (Total Children Is Unduplicated) 17498 47729.25000 1292176.0000 27.0730
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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 115 170.000000 8475.0000 49.8529
EXIT-EXIT-EXIT ASSESSMENT 648 1016.500000 50787.5000 49.9631
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 42 51.000000 3359.9100 65.8806
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 16 21.500000 1369.9100 63.7167
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 24 28.500000 2047.5000 71.8421
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 58 70.000000 3885.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 484 695.781367 50584.7000 72.7020
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 195 288.846533 20829.1800 72.1116
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 163 232.000000 17176.4900 74.0366
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 760 993.500000 54809.4200 55.1680
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 368 526.509333 38819.8400 73.7306
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 12 12.000000 486.0000 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 45 69.000000 3450.0000 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 143 146.000000 7414.0700 50.7813
SPCH-92524-BEHAV & QUAL ANALYSIS OF
VOICE AND RES 5 5.000000 255.2500 51.0500
Subtotal (Total Children Is Unduplicated) 2362 4642.657801 276470.6200 59.5501
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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 990 1139.500000 56946.7500 49.9752
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 27 19.750000 493.7500 25.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 1952 3265.250000 163178.7500 49.9744
CONIP-CONIP-CONSULT, ITDS PHONE 125 112.000000 2800.0000 25.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 317 446.500000 22325.0000 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 2746 16407.50000 818554.8300 49.8891
INTR-T1013-INTERPRETER 428 1368.750000 66972.0000 48.9293
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 13169 98412.00000 985787.9700 10.0169
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 592 2465.801215 169224.5300 68.6286
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 1567 8172.579988 572457.0940 70.0461
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 4831 375014.0000 166644.6800 0.4444
Subtotal (Total Children Is Unduplicated) 14279 512014.0439 3348992.5740 6.5408
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Total 564385.951721 4917639.1940 8.7133
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Number of Children (Unduplicated) With at Least One Service 21890
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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 3250 14306.750000 52208.2600 52176.6800
D 196 814.500000 6352.5100 385.1200
S 123 199.250000 5696.3400 60.0000
H 0 0.000000 0.0000 0.0000
T 12790 55497.750000 241112.9200 237068.5800
6485 4630.250000 133734.1700 94.5400
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 22844 75448.500000 439104.2000 289784.9200
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
898 2261.500000 27605.8900 0.0000
Other 3087 5737.250000 46286.5700 0.0000
---------------------------------------------------------
Total 7643 19115.500000 168433.3600 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 0 0.000000 0.0000 0.0000
P 0 0.000000 0.0000 0.0000
D 45 28.000000 1042.5000 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
12109 44558.500000 217594.1800 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 12154 44586.500000 218636.6800 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 2628 9305.250000 155350.4400 155350.4400
D 36 59.500000 2201.5000 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
3151 2846.750000 117887.5100 0.0000
Other 35 90.000000 4329.9400 1779.3400
---------------------------------------------------------
Total 5899 12468.500000 281491.2800 158861.2200
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 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
2841 2529.000000 56313.2700 917.5000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 6666 53128.000000 182907.9040 127539.0750
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
11239 7328.250000 203833.4500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 18311 14024.000000 362406.6800 158573.2300
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 3038 8410.250000 171764.9400 171764.9400
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
6447 3936.250000 116207.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 9485 12346.500000 287971.9400 171764.9400
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 12748 72871.500000 503752.6700 503752.6700
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 2499 23489.750000 116722.8000 116722.8000
3957 3125.000000 111644.1600 1908.7900
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 19204 99486.250000 732119.6300 622384.2600
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
3029 2105.500000 59463.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 9367 21115.750000 531771.7300 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 2087 6732.000000 215478.7700 215459.7900
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
5323 3261.750000 107895.5500 70.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 7410 9993.750000 323374.3200 215529.7900
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 5720 58151.750000 209373.4300 203967.1800
2984 1938.000000 44262.9200 157.1000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 8713 60136.250000 254137.7800 204625.7100
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 2004 13227.750000 23720.8300 23720.8300
T 0 0.000000 0.0000 0.0000
14434 29777.259333 177821.3600 0.0000
Other 10 10.000000 100.0000 0.0000
---------------------------------------------------------
Total 16448 43015.009333 201642.1900 23720.8300
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 3881 23194.250000 52899.1500 52899.1500
T 1 1.000000 303.4000 303.4000
16896 37163.000000 208953.2900 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 20778 60358.250000 262155.8400 53202.5500
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 5849 6903.871740 142938.2600 142938.2600
D 1 2.000000 150.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 2 4.000000 300.0000 0.0000
T 0 0.000000 0.0000 0.0000
5870 5167.600648 145668.4200 52324.1300
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 11722 12077.472388 289056.6800 195262.3900
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 3572 23886.720000 263285.0800 263285.0800
3072 2810.500000 110894.6600 50.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 6770 27085.720000 382428.9800 270880.3200