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: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 11299 13062.50000 483175.7500 36.9895
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 8513 13198.00000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 7053 20698.00000 765430.2500 36.9809
Subtotal (Total Children Is Unduplicated) 17510 46958.50000 1248606.0000 26.5896
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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 150 308.250000 15388.5500 49.9223
EXIT-EXIT-EXIT ASSESSMENT 666 1055.000000 52750.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 48 69.500000 5212.5000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 27 31.500000 2235.0200 70.9530
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 13 21.000000 1489.9600 70.9505
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 30 35.500000 2570.5200 72.4090
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 62 82.000000 4477.7200 54.6063
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 626 935.067930 67638.0599 72.3349
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 196 289.041800 20727.8400 71.7123
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 177 267.091600 19768.7600 74.0149
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 857 1189.500000 65056.5000 54.6923
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 374 587.500000 43503.3200 74.0482
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 17 17.000000 688.5000 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 48 95.000000 4725.0000 49.7368
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) 2529 5416.461630 326201.9499 60.2242
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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 433 1348.250000 64786.3600 48.0522
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 13247 106615.0000 1067287.7100 10.0107
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 4926 404028.0000 177912.4200 0.4403
Subtotal (Total Children Is Unduplicated) 14443 554087.1771 3709638.8511 6.6950
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Total 606462.138772 5284446.8010 8.7136
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Number of Children (Unduplicated) With at Least One Service 21665
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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 16015 71683.000000 292593.5200 292593.5200
D 617 3142.250000 20260.5700 10.0000
S 102 110.250000 5573.2200 112.5000
H 0 0.000000 0.0000 0.0000
T 671 3674.000000 9727.9800 9727.9500
5977 4563.750000 117444.9000 50.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 23382 83173.250000 445600.1900 302493.9700
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 4342 12609.750000 116327.3700 116195.2300
224 411.500000 7410.1900 0.0000
Other 2776 7409.000000 47579.0500 0.0000
---------------------------------------------------------
Total 7342 20430.250000 171316.6100 116195.2300
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
9924 29335.250000 210979.8600 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 9969 29367.750000 212258.3600 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 3005 10700.500000 186440.2400 186440.0800
D 51 86.000000 3103.5000 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
3003 2620.000000 107509.2700 0.0000
Other 18 46.000000 3058.0400 1521.7600
---------------------------------------------------------
Total 6094 13511.500000 300701.0500 188591.8400
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 4611 54781.250000 159379.1900 159421.6300
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 7302 56373.250000 207401.6900 159899.3800
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
11599 8067.250000 213915.5700 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 18003 14181.000000 350553.4100 136637.8400
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 4488 12240.750000 249234.9400 249164.9400
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
6639 4200.000000 122987.5000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 11214 16508.000000 374975.6900 249164.9400
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 18608 125023.250000 735896.1500 735896.1500
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
558 1329.500000 21961.9500 0.0000
Other 1 2.000000 150.0000 0.0000
---------------------------------------------------------
Total 19167 126354.750000 758008.1000 735896.1500
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
5752 4152.000000 130350.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 14477 29521.750000 772284.2300 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 2260 6792.250000 204594.1500 204575.6500
D 4 5.000000 241.5000 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
4821 2925.250000 97252.3900 80.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 7085 9722.500000 302088.0400 204655.6500
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 5 17.000000 348.7500 346.2000
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 6435 60151.750000 225672.8000 221335.8600
3029 1974.250000 46270.8900 80.8900
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 9474 62148.750000 272681.7800 221762.9500
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 1867 13560.500000 23203.6000 23203.6000
13623 27376.250000 170941.3500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 15490 40936.750000 194144.9500 23203.6000
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 3530 22840.980000 54111.5600 54111.5600
T 4256 25952.750000 58120.1800 58120.1800
14061 17738.460000 169913.1800 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 21850 66535.190000 282183.5700 112231.7400
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 8512 10053.078942 210609.0111 210609.0100
D 22 42.750000 3177.7500 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
3532 2212.024930 76077.1199 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 12066 12307.853872 289863.8810 210609.0100
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 157 352.750000 10306.7600 10306.7200
H 0 0.000000 0.0000 0.0000
T 3258 22384.344900 235089.7400 235089.7400
2911 2640.000000 104526.2500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 6335 25389.594900 350385.2500 245396.4600