CMS/EIP Fiscal Report Statewide
Services beginning 10/01/2016 ending 12/31/2016 Date of Report:02/04/2017 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 10495 12331.25000 456128.7500 36.9897
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 7759 12080.00000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 6468 18609.00000 688183.5000 36.9812
Subtotal (Total Children Is Unduplicated) 16218 43020.25000 1144312.2500 26.5994
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Screening, Eval, and Assessment,Class #02
ASTE-ASTE-ASSISTIVE TECHNOLOGY EVAL 23 25.000000 1212.5000 48.5000
AUDE-92552-PURE TONE AUDIOMETRY -AIR ONLY 6 6.000000 89.5800 14.9300
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 7 7.000000 72.9400 10.4200
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 13 13.000000 113.7500 8.7500
AUDE-92568-ACOUSTIC REFLEX TESTING (MEMR) 3 3.000000 24.1800 8.0600
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 14 14.000000 305.7600 21.8400
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 9 9.000000 206.1000 22.9000
AUDE-V5010-ASSESSMENT FOR HEARING AID 1 1.000000 46.8000 46.8000
BEHV-BEHV-BEHAVIORAL ASSESSMENT 1 1.000000 125.0000 125.0000
EVAL-96111-DEVELOPMENTAL EVALUATION 110 201.500000 10051.0500 49.8811
EXIT-EXIT-EXIT ASSESSMENT 666 1055.000000 52750.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 43 61.500000 4612.5000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 26 29.500000 2085.0200 70.6786
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 12 19.500000 1377.4600 70.6390
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 28 31.500000 2270.5200 72.0800
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 53 69.500000 3842.2500 55.2842
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 474 704.048597 51010.0499 72.4525
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 146 220.541800 15950.0100 72.3219
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 129 193.091600 14481.8700 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 648 884.000000 48429.8700 54.7849
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 277 427.000000 31774.0200 74.4122
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 13 13.000000 526.5000 40.5000
MED-99204-OUTPATIENT VISIT, NEW, 45 MINS 1 1.000000 57.2700 57.2700
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 5 5.000000 110.7000 22.1400
NUTR-97803-NUTRITIONAL EVAL, FOLLOW-UP 20 40.000000 2000.0000 50.0000
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 5 5.000000 255.2500 51.0500
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 79 79.000000 3969.5500 50.2475
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 7 9.000000 444.4500 49.3833
PSTH-97001-EVAL BY LICENSED PT, INITIAL 47 46.510300 2374.3500 51.0500
SCREEN-T1023-SCREENING 46 92.000000 4575.0000 49.7283
SPCH-92522-EVAL OF SPCH SOUND PROD 1 1.000000 51.0500 51.0500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 155 159.000000 8051.0200 50.6353
SPCH-92524-BEHAV & QUAL ANALYSIS OF
VOICE AND RES 9 9.000000 459.4500 51.0500
Subtotal (Total Children Is Unduplicated) 2149 4435.192297 263705.8199 59.4576
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 49 88.640000 16401.9500 185.0400
AUD-92592TS-AUDIOLOGY SERVICES (Monaural) 1 1.000000 50.0000 50.0000
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 1144 1270.250000 63437.5000 49.9410
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 53 42.000000 1043.7500 24.8512
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 2077 3494.750000 174650.0000 49.9750
CONIP-CONIP-CONSULT, ITDS PHONE 207 182.250000 4530.5000 24.8587
CONOF-CONOF-CONSULT, OT, FACE TO FACE 329 446.500000 22325.0000 50.0000
CONOP-CONOP-CONSULT, OT, PHONE 33 32.500000 812.5000 25.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 245 357.500000 17875.0000 50.0000
CONPP-CONPP-CONSULT, PT, PHONE 13 14.250000 356.2500 25.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 720 871.500000 43575.0000 50.0000
CONSP-CONSP-CONSULT, SLP, PHONE 48 62.000000 1550.0000 25.0000
COUN-H2019HR-INDIVIDUAL/FAMILY THERAPY 14 41.000000 3006.1200 73.3200
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 28 146.000000 3650.0000 25.0000
EIIF-96154-HEALTH AND BEHAVIOR INTERVENTION 6 164.000000 8200.0000 50.0000
EIIF-EIIF_NM-EI INDIVIDUAL SESSION BY NONMED PROF 13 58.000000 2900.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 2768 18389.75000 916493.3900 49.8372
INTR-T1013-INTERPRETER 390 1261.500000 60292.3600 47.7942
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 13003 106165.0000 1062777.7100 10.0106
OCCT-97530-OT SESSION BY LICENSED OT 593 2841.531582 194991.6500 68.6220
OCCT-97530HM-OT SESSION BY OT ASST 140 716.762931 40699.4000 56.7822
PHY-97110-PT SESSION BY LICENSED PT 653 3175.481142 214865.2899 67.6639
PHY-97110HM-PT SESSION BY PT ASST 62 390.692180 22249.0400 56.9477
SENS-V5264-EARMOLD 4 8.000000 144.0000 18.0000
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 1602 9269.069307 644359.3212 69.5172
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 5 24.500000 1401.4000 57.2000
SPL-92508-GROUP SPL SESSION PER CHILD 5 8.000000 85.3000 10.6625
TRAV-TRAVS-Travel by mile 4725 398315.0000 175379.3100 0.4403
Subtotal (Total Children Is Unduplicated) 14072 547837.4271 3698101.7411 6.7504
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Total 595292.869439 5106119.8110 8.5775
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Number of Children (Unduplicated) With at Least One Service 20296
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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 15937 70980.000000 288647.2900 288647.2900
D 602 3050.250000 19608.3300 10.0000
S 102 110.250000 5573.2200 112.5000
H 0 0.000000 0.0000 0.0000
T 669 3647.500000 9633.7800 9633.7500
5508 4181.000000 104850.6500 50.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 22818 81969.000000 428313.2700 298453.5400
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 4286 11415.750000 113731.9600 113599.8200
222 253.500000 7339.8800 0.0000
Other 2500 6995.000000 43653.2100 0.0000
---------------------------------------------------------
Total 7008 18664.250000 164725.0500 113599.8200
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 32.500000 1278.5000 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
9438 28852.500000 190291.8600 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 9483 28885.000000 191570.3600 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 3003 10697.500000 186410.2400 186410.0800
D 48 77.500000 2789.0000 40.0000
S 0 0.000000 0.0000 0.0000
H 17 59.000000 590.0000 590.0000
T 0 0.000000 0.0000 0.0000
2748 2397.250000 98296.5200 0.0000
Other 18 46.000000 3058.0400 1521.7600
---------------------------------------------------------
Total 5834 13277.250000 291143.8000 188561.8400
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 4515 54163.750000 155526.2000 155568.6400
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
2464 1421.250000 43051.7500 477.7500
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 6979 55585.000000 198577.9500 156046.3900
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 6401 6107.750000 136260.8400 136260.8400
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
11255 7828.500000 206102.8200 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 17656 13936.250000 342363.6600 136260.8400
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 4443 12169.250000 247948.8600 247878.8600
D 76 55.250000 2309.2500 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
5991 3581.750000 107736.5000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 10510 15806.250000 357994.6100 247878.8600
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 18214 124549.250000 721147.0900 721147.0900
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
511 1275.000000 19695.9500 0.0000
Other 1 2.000000 150.0000 0.0000
---------------------------------------------------------
Total 18726 125826.250000 740993.0400 721147.0900
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 8652 25331.000000 640500.4800 640500.4800
D 71 38.250000 1415.2500 0.0000
S 2 0.500000 18.5000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
5323 3709.750000 113673.2500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 14048 29079.500000 755607.4800 640500.4800
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 2244 6776.250000 204164.1500 204145.6500
D 3 3.500000 186.0000 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
4648 2812.500000 93429.1400 80.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 6895 9592.250000 297779.2900 204225.6500
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 4 15.000000 265.5000 262.9500
D 5 5.750000 389.3400 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 6329 58836.250000 223170.6000 218836.6600
2853 1826.000000 41458.6400 80.8900
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 9191 60683.000000 265284.0800 219180.5000
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 0 0.000000 0.0000 0.0000
T 1854 13454.500000 22875.4300 22875.4300
13149 26855.000000 161786.2300 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 15003 40309.500000 184661.6600 22875.4300
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 3 3.000000 38.6500 0.0000
H 3456 22299.480000 52549.5100 52549.5100
T 4177 25306.750000 56429.4400 56429.4400
13281 17005.710000 157805.8100 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 20917 64614.940000 266823.4100 108978.9500
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 8480 10005.078942 208255.0111 208255.0100
D 14 26.750000 1977.7500 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
3187 1968.755597 67350.4199 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 11681 12000.584539 277583.1810 208255.0100
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 9 12.500000 462.5000 0.0000
S 153 348.750000 10266.7600 10266.7200
H 0 0.000000 0.0000 0.0000
T 3253 22233.344900 234744.2100 234744.2100
2761 2469.250000 97225.5000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 6176 25063.844900 342698.9700 245010.9300