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
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 11305 13066.50000 483323.7500 36.9895
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 8519 13253.00000 1300.0000 0.0981
TCM-T1017TL-TARGETED CASE MANAGEMENT 21335 63893.50000 2362586.0000 36.9769
Subtotal (Total Children Is Unduplicated) 22593 90213.00000 2847209.7500 31.5610
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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) 8 8.000000 83.3600 10.4200
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 15 15.000000 131.2500 8.7500
AUDE-92568-ACOUSTIC REFLEX TESTING (MEMR) 4 4.000000 32.2400 8.0600
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 15 15.000000 327.6000 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 152 314.250000 18369.5500 58.4552
EXIT-EXIT-EXIT ASSESSMENT 671 1063.000000 53150.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 168 287.166667 21537.5000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 90 152.000000 11272.5200 74.1613
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 46 66.000000 4800.0000 72.7273
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 139 212.000000 16123.7700 76.0555
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 207 346.000000 19079.7200 55.1437
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 2380 3711.333433 275160.5203 74.1406
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 982 1485.500100 110026.5200 74.0670
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 667 998.500000 74384.6500 74.4964
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 2789 4300.000000 236993.2400 55.1147
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 1368 2153.000000 161681.7400 75.0960
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 64 64.000000 6281.0000 98.1406
MED-99204-OUTPATIENT VISIT, NEW, 45 MINS 1 1.000000 57.2700 57.2700
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 15 15.000000 673.8200 44.9213
NUTR-97803-NUTRITIONAL EVAL, FOLLOW-UP 36 182.000000 9100.0000 50.0000
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 9 9.000000 459.4500 51.0500
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 127 128.000000 6447.5500 50.3715
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 13 15.000000 750.7500 50.0500
PSTH-97001-EVAL BY LICENSED PT, INITIAL 92 93.000100 8940.3000 96.1322
SCREEN-T1023-SCREENING 124 180.000000 8975.0000 49.8611
SPCH-92521-EVAL OF SPEECH FLUENCY 2 2.000000 102.1000 51.0500
SPCH-92522-EVAL OF SPCH SOUND PROD 1 1.000000 51.0500 51.0500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 209 215.000000 10909.8200 50.7433
SPCH-92524-BEHAV & QUAL ANALYSIS OF
VOICE AND RES 12 12.000000 612.6000 51.0500
Subtotal (Total Children Is Unduplicated) 5790 16089.75030 1058194.8703 65.7683
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 51 98.000000 17296.5200 176.4951
AUD-92592TS-AUDIOLOGY SERVICES (Monaural) 1 1.000000 50.0000 50.0000
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 1186 1330.750000 66462.5000 49.9436
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 65 53.500000 1331.2500 24.8832
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 2113 3577.750000 178800.0000 49.9755
CONIP-CONIP-CONSULT, ITDS PHONE 222 232.250000 5780.5000 24.8891
CONOF-CONOF-CONSULT, OT, FACE TO FACE 339 459.000000 22950.0000 50.0000
CONOP-CONOP-CONSULT, OT, PHONE 40 42.500000 1062.5000 25.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 264 393.250000 19662.5000 50.0000
CONPP-CONPP-CONSULT, PT, PHONE 18 33.250000 831.2500 25.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 739 911.000000 45550.0000 50.0000
CONSP-CONSP-CONSULT, SLP, PHONE 49 79.000000 1975.0000 25.0000
COUN-H2019HR-INDIVIDUAL/FAMILY THERAPY 18 51.000000 3739.3200 73.3200
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 118 5704.000000 142600.0000 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 8462 58109.75000 2901967.9100 49.9394
INTR-T1013-INTERPRETER 433 1374.250000 66010.3600 48.0337
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 13248 106787.0000 1067975.7700 10.0010
OCCT-97530-OT SESSION BY LICENSED OT 1059 5471.894598 382768.4800 69.9517
OCCT-97530HM-OT SESSION BY OT ASST 349 1667.750000 94992.6600 56.9586
PHY-97110-PT SESSION BY LICENSED PT 1106 5791.747199 411016.4907 70.9659
PHY-97110HM-PT SESSION BY PT ASST 190 980.750100 56199.5900 57.3027
SENS-V5264-EARMOLD 4 8.000000 144.0000 18.0000
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 2486 15089.99990 1134147.1900 75.1589
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 112 313.500000 17932.2000 57.2000
SPL-92508-GROUP SPL SESSION PER CHILD 16 42.000000 557.2200 13.2671
TRAV-TRAVS-Travel by mile 5038 440875.0000 194173.8600 0.4404
Subtotal (Total Children Is Unduplicated) 15004 649699.8918 6847077.0707 10.5388
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Total 756002.642097 10752481.6910 14.2228
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Number of Children (Unduplicated) With at Least One Service 24139
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Center 01
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 47 22.250000 823.2500 0.0000
U 0 0.000000 0.0000 0.0000
B 7156 4688.000000 173690.0000 0.0000
P 16058 71727.250000 295135.2400 295135.2400
D 917 3529.250000 46080.1500 10.0000
S 1070 1113.750000 61531.5900 112.5000
H 30 39.500000 2944.7000 0.0000
T 677 3713.000000 10123.4900 10123.4600
6008 4586.250000 118673.9000 50.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 31963 89419.250000 709002.3200 305431.2000
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 4343 12653.750000 116346.9500 116214.8100
237 423.000000 8125.6000 0.0000
Other 4299 8546.750000 95866.8000 0.0000
---------------------------------------------------------
Total 8879 21623.500000 220339.3500 116214.8100
Center 03
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 131 85.500000 3686.7500 0.0000
P 3149 1984.250000 82946.8000 32646.3000
D 45 32.500000 1278.5000 0.0000
S 0 0.000000 0.0000 0.0000
H 175 171.250000 65013.2300 0.0000
T 0 0.000000 0.0000 0.0000
10123 29523.500000 270847.9400 0.0000
Other 48 45.250000 1778.2500 0.0000
---------------------------------------------------------
Total 13671 31842.250000 425551.4700 32646.3000
Center 04
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 3 7.500000 277.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 65 102.500000 3792.5000 0.0000
P 6382 15472.750000 377899.6400 378392.0400
D 51 86.000000 3103.5000 40.0000
S 3 9.250000 407.2500 0.0000
H 2111 7808.500000 392068.6700 947.2000
T 1 1.500000 55.5000 0.0000
3748 8644.000000 293263.4000 0.0000
Other 47 108.500000 7398.7600 2200.4400
---------------------------------------------------------
Total 12411 32240.500000 1078266.7200 381579.6800
Center 05
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 2524 1708.000000 70729.7500 0.0000
P 4614 54829.250000 159577.8800 159620.3200
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
2691 1592.000000 48022.5000 477.7500
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 9829 58129.250000 278330.1300 160098.0700
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 6404 6113.750000 136637.8400 136637.8400
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
19379 14435.500000 524137.4200 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 25783 20549.250000 660775.2600 136637.8400
Center 07
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 6 4.750000 175.7500 0.0000
U 0 0.000000 0.0000 0.0000
B 228 154.500000 5868.2500 0.0000
P 9935 16430.000000 422069.6900 421962.6900
D 87 67.250000 2753.2500 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
6682 4271.750000 126385.3000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 16938 20928.250000 557252.2400 421962.6900
Center 09
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 117 120.000000 5470.5000 101.7500
P 24780 166293.750000 1060222.2400 1059753.1500
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
3081 9390.750000 425061.5900 0.0000
Other 129 185.000000 13844.6600 0.0000
---------------------------------------------------------
Total 28107 175989.500000 1504598.9900 1059854.9000
Center 10
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 77 47.250000 1748.2500 0.0000
U 0 0.000000 0.0000 0.0000
B 9325 6685.500000 281593.2500 0.0000
P 8653 25331.500000 640520.0400 640520.0400
D 71 38.250000 1415.2500 0.0000
S 191 151.500000 5605.5000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
9204 14833.250000 696899.5600 0.0000
Other 1 0.250000 9.2500 0.0000
---------------------------------------------------------
Total 27522 47087.500000 1627791.1000 640520.0400
Center 51
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 53 36.000000 1332.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 2532 1619.750000 63368.7500 0.0000
P 2260 6792.250000 204594.1500 204575.6500
D 9 8.250000 361.7500 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
5736 5620.250000 260841.3100 80.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 10590 14076.500000 530497.9600 204655.6500
Center 52
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 9 12.000000 750.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 949 1010.500000 52482.5000 175.7500
P 1906 1710.750000 75262.6400 72524.5900
D 169 178.250000 10746.4400 40.0000
S 44 52.000000 2964.3200 0.0000
H 146 147.000000 9886.2800 0.0000
T 6458 60260.000000 227384.1200 222433.9900
4346 4261.250000 180110.0300 560.8500
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 14027 67631.750000 559586.3300 295735.1800
Center 53
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 6 4.250000 157.2500 0.0000
U 0 0.000000 0.0000 0.0000
B 554 535.750000 26091.0000 0.0000
P 2931 2805.000000 125711.0000 125711.0000
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 1867 13560.500000 23203.6000 23203.6000
16275 30195.500000 311155.6200 0.0000
Other 18 17.000000 884.2500 0.0000
---------------------------------------------------------
Total 21651 47118.000000 487202.7200 148914.6000
Center 54
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 3 2.000000 74.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 5199 4305.500000 185784.0000 50.0000
P 722 746.000000 39899.5000 39915.2500
D 0 0.000000 0.0000 0.0000
S 4 3.250000 47.9000 0.0000
H 3530 22840.980000 54111.5600 54111.5600
T 4256 25952.750000 58120.1800 58120.1800
17025 21497.270000 321275.1300 92809.7300
Other 4 2.750000 101.7500 0.0000
---------------------------------------------------------
Total 30743 75350.500000 659414.0200 245006.7200
Center 55
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 30 25.500000 943.5000 0.0000
P 11752 13137.078942 339172.2611 339172.2600
D 22 42.750000 3177.7500 0.0000
S 0 0.000000 0.0000 0.0000
H 16 30.990400 2324.2800 0.0000
T 0 0.000000 0.0000 0.0000
7598 5913.572755 307926.4399 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 19418 19149.892097 653544.2310 339172.2600
Center 57
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 3 3.000000 111.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 2644 2529.500000 104101.2500 0.0000
P 946 976.905100 36281.0500 35936.8000
D 11 16.000000 592.0000 0.0000
S 157 352.750000 10306.7600 10306.7200
H 0 0.000000 0.0000 0.0000
T 3259 22382.344900 234989.7400 234989.7400
4961 8544.250000 412266.9600 307278.8000
Other 39 62.000000 1680.0900 1652.3400
---------------------------------------------------------
Total 12020 34866.750000 800328.8500 590164.4000