CMS/EIP Fiscal Report Statewide
Services beginning 01/01/2017 ending 03/31/2017 Date of Report:05/05/2017 Page: 1
List order: No List
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 11291 12226.00000 452220.0000 36.9884
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 8570 13059.00000 521.4400 0.0399
TCM-T1017TL-TARGETED CASE MANAGEMENT 21249 66468.25000 2457925.8400 36.9789
Subtotal (Total Children Is Unduplicated) 22237 91753.25000 2910667.2800 31.7228
-----------------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
ASTE-ASTE-ASSISTIVE TECHNOLOGY EVAL 24 24.000000 1164.0000 48.5000
AUDE-92552-PURE TONE AUDIOMETRY -AIR ONLY 35 35.000000 627.2000 17.9200
AUDE-92553-PURE TONE AUDIOMETRY AIR & BONE 1 1.000000 21.3500 21.3500
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 46 46.000000 577.8700 12.5624
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 50 50.000000 413.0000 8.2600
AUDE-92568-ACOUSTIC REFLEX TESTING (MEMR) 5 5.000000 45.3000 9.0600
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 49 49.000000 1236.7200 25.2392
AUDE-92585-AUD EVOKED RESPONSE (COMP) 1 1.000000 77.1300 77.1300
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 23 23.000000 430.6900 18.7257
AUDE-92588-OTOACOUSTIC EMISSIONS (COMP) 6 6.000000 124.0800 20.6800
AUDE-V5010-ASSESSMENT FOR HEARING AID 3 3.000000 135.0000 45.0000
AUDE-V5090-DISPENSING FEE PER HEARING AID 4 7.000000 805.0000 115.0000
BEHV-BEHV-BEHAVIORAL ASSESSMENT 1 1.000000 125.0000 125.0000
EVAL-96111-DEVELOPMENTAL EVALUATION 137 221.500000 10010.1200 45.1924
EXIT-EXIT-EXIT ASSESSMENT 735 1168.000000 58400.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 146 231.000000 17203.1000 74.4723
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 75 144.500000 10804.8400 74.7740
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 42 53.000000 3975.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 130 206.000000 15297.5200 74.2598
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 192 317.500000 17556.2500 55.2953
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 1998 3114.000097 231690.1697 74.4027
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 795 1180.500400 87177.9000 73.8483
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 635 951.000100 70985.0200 74.6425
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 2360 3624.000000 200474.9700 55.3187
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 1346 2020.500031 151572.5123 75.0173
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 81 81.000000 7012.8800 86.5788
MED-99204-OUTPATIENT VISIT, NEW, 45 MINS 1 1.000000 75.7200 75.7200
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 15 15.000000 880.4400 58.6960
NUTR-97802-NUTRITIONAL EVAL, INITIAL 1 2.000000 100.0000 50.0000
NUTR-97803-NUTRITIONAL EVAL, FOLLOW-UP 34 168.000000 8400.0000 50.0000
OCTF-97168-OT RE-EVAL EST PLAN CARE 17 18.000000 918.9000 51.0500
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 7 7.000000 357.3500 51.0500
OCTH-97165-OT EVAL LOW COMPLEXITY 15 16.000000 791.8000 49.4875
OCTH-97166-OT EVAL MODERATE COMPLEXITY 44 44.000000 2243.1400 50.9805
OCTH-97167-OT EVAL HIGH COMPLEXITY 85 87.000000 4441.3500 51.0500
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 1 1.000000 51.0500 51.0500
PSTF-97164-PT RE-EVAL EST PLAN CARE 9 9.000000 459.4500 51.0500
PSTH-97001-EVAL BY LICENSED PT, INITIAL 3 3.000000 153.1500 51.0500
PSTH-97161-PT EVAL LOW COMPLEXITY 10 10.000000 1159.4500 115.9450
PSTH-97162-PT EVAL MODERATE COMPLEXITY 15 15.000000 765.7500 51.0500
PSTH-97163-PT EVAL HIGH COMPLEXITY 70 71.000000 3574.5500 50.3458
SCREEN-T1023-SCREENING 108 118.000000 5900.0000 50.0000
SPCH-92521-EVAL OF SPEECH FLUENCY 4 4.000000 204.2000 51.0500
SPCH-92522-EVAL OF SPCH SOUND PROD 3 3.000000 153.1500 51.0500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 229 232.000000 11748.4200 50.6397
SPCH-92524-BEHAV & QUAL ANALYSIS OF
VOICE AND RES 11 11.000000 561.5500 51.0500
Subtotal (Total Children Is Unduplicated) 5319 14398.50063 930882.0420 64.6513
-----------------------------------------------------------------------------------------------------------------------
EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 52 109.000000 34508.3600 316.5905
AUDE-V5160-DISPENSING FEE BINAURAL 1 1.000000 230.0000 230.0000
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 1314 1567.500000 75850.0000 48.3892
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 60 52.500000 1312.5000 25.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 2025 3454.250000 172462.5000 49.9276
CONIP-CONIP-CONSULT, ITDS PHONE 205 165.750000 4109.0000 24.7903
CONOF-CONOF-CONSULT, OT, FACE TO FACE 451 683.000000 34150.0000 50.0000
CONOP-CONOP-CONSULT, OT, PHONE 37 33.500000 837.5000 25.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 364 493.750000 24437.5000 49.4937
CONPP-CONPP-CONSULT, PT, PHONE 9 11.250000 281.2500 25.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 1030 1254.750000 62737.5000 50.0000
CONSP-CONSP-CONSULT, SLP, PHONE 95 81.000000 2025.0000 25.0000
COUN-H2019HR-INDIVIDUAL/FAMILY THERAPY 15 49.000000 3592.6800 73.3200
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 113 5771.750000 144293.7500 25.0000
EIIF-96154-HEALTH AND BEHAVIOR INTERVENTION 6 180.500000 9025.0000 50.0000
EIIF-EIIF_NM-EI INDIVIDUAL SESSION BY NONMED PROF 13 59.500000 2975.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 8772 63140.75000 3155866.9500 49.9815
INTR-T1013-INTERPRETER 421 1473.050000 70146.2900 47.6198
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 12174 101092.0000 1014965.8420 10.0400
OCCT-97530-OT SESSION BY LICENSED OT 1034 5613.250700 393432.9400 70.0900
OCCT-97530HM-OT SESSION BY OT ASST 358 1714.251200 98001.7500 57.1688
PHY-97110-PT SESSION BY LICENSED PT 1151 6902.043600 531768.5351 77.0451
PHY-97110HM-PT SESSION BY PT ASST 171 961.000000 54807.4900 57.0317
SENS-V5050-IN EAR MONAURAL HEARING AID 3 6.000000 1912.0000 318.6667
CMS/EIP Fiscal Report Statewide
Services beginning 01/01/2017 ending 03/31/2017 Date of Report:05/05/2017 Page: 2
List order: No List
Eligibility Filter:Part C (excluding not eligible)
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
SENS-V5140-BEHIND THE EAR BINAURAL HEARING AID
1 1.000000 456.0000 456.0000
SENS-V5264-EARMOLD 6 10.000000 180.0000 18.0000
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 2419 15752.84607 1142969.9800 72.5564
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 103 298.500000 17074.2000 57.2000
SPL-92508-GROUP SPL SESSION PER CHILD 24 39.500000 1191.9400 30.1757
TRAV-TRAVS-Travel by mile 5160 481878.0000 212881.2700 0.4418
Subtotal (Total Children Is Unduplicated) 15092 692850.1916 7268482.7271 10.4907
-----------------------------------------------------------------------------------------------------------------------
Total 799001.942194 11110032.0491 13.9049
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 23683
-----------------------------------------------------------------------------------------------------------------------
Center 01
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 86 73.000000 4689.9400 0.0000
U 0 0.000000 0.0000 0.0000
B 8307 5391.250000 205731.0200 0.0000
P 16030 67147.750000 291756.7220 291756.7200
D 1739 6989.750000 50514.3100 0.0000
S 464 504.750000 32691.5800 0.0000
H 114 139.750000 10008.1000 0.0000
T 1899 8714.500000 34906.6500 34748.2000
6499 4275.750000 130169.5500 88.0200
Other 1 1.000000 71.4400 0.0000
---------------------------------------------------------
Total 35139 93237.500000 760539.3120 326592.9400
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 4613 8616.750000 142349.5400 141022.2540
400 378.750000 7787.9300 0.0000
Other 5198 14066.750000 113956.9700 0.0000
---------------------------------------------------------
Total 10211 23062.250000 264094.4400 141022.2540
Center 03
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 983 608.750000 23915.0000 100.0000
P 2155 1341.250000 55341.7500 39978.0250
D 18 10.500000 388.5000 0.0000
S 5 4.250000 157.2500 0.0000
H 207 198.750000 48774.0900 0.0000
T 0 0.000000 0.0000 0.0000
13214 45561.500000 284671.6700 0.0000
Other 60 48.500000 1937.5000 0.0000
---------------------------------------------------------
Total 16642 47773.500000 415185.7600 40078.0250
Center 04
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 1 1.000000 55.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 741 930.750000 41169.0000 0.0000
P 6657 17891.000000 425855.5500 425820.0600
D 83 108.250000 4042.7500 0.0000
S 2 2.000000 74.0000 0.0000
H 2272 8918.500000 449280.2000 348.6400
T 0 0.000000 0.0000 0.0000
4549 9894.500000 341708.4900 0.0000
Other 64 152.000000 9647.2000 3520.3300
---------------------------------------------------------
Total 14369 37898.000000 1271832.6900 429689.0300
Center 05
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 1 1.000000 37.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 2834 1909.250000 77157.7500 0.0000
P 4692 58891.050000 164944.9300 165054.8580
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
2737 1629.500000 44636.8700 283.1200
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 10264 62430.800000 286776.5500 165337.9780
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 10724 10165.500000 228705.6500 228705.6500
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
18877 13582.750000 561072.5700 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 29601 23748.250000 789778.2200 228705.6500
Center 07
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 2 0.750000 27.7500 0.0000
U 0 0.000000 0.0000 0.0000
B 13 9.250000 342.2500 0.0000
P 10966 16055.750000 424231.7600 424176.2600
D 131 89.000000 3584.0000 0.0000
S 3 1.250000 46.2500 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
6959 4220.500000 128716.5500 0.0000
Other 1 1.000000 37.0000 0.0000
---------------------------------------------------------
Total 18075 20377.500000 556985.5600 424176.2600
Center 09
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 2 3.500000 129.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 220 191.750000 7419.7500 27.7500
P 19123 153422.250000 853274.4300 853432.8300
D 7 10.000000 671.0700 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
2924 11777.000000 453023.7000 163.9600
Other 160 242.000000 17939.7500 0.0000
---------------------------------------------------------
Total 22436 165646.500000 1332458.2000 853624.5400
Center 10
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 529 368.000000 13616.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 7035 5144.750000 217016.5000 0.0000
P 10340 26789.000000 710801.5700 710470.1300
D 102 66.500000 2460.5000 0.0000
S 61 33.500000 1391.5000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
8942 14485.000000 737829.5600 60.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 27009 46886.750000 1683115.6300 710530.1300
Center 51
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 6 6.500000 278.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 2315 1476.250000 57329.0000 0.0000
P 1864 5844.750000 175962.8100 175962.8000
D 8 3.250000 120.2500 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
4613 4959.750000 234306.6500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 8806 12290.500000 467997.2100 175962.8000
Center 52
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 265 188.750000 7672.0000 37.0000
P 2946 2668.750000 124907.0000 121355.5600
D 83 95.750000 6128.9900 0.0000
S 6 6.000000 222.0000 0.0000
H 91 90.500000 5878.6200 46.9000
T 7219 62734.250000 277287.2300 266348.5800
4288 4460.250000 177542.7400 2694.2300
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 14898 70244.250000 599638.5800 390482.2700
Center 53
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 133 137.250000 6642.2500 0.0000
P 3810 3549.425000 159377.6400 158416.0000
D 3 3.000000 150.0000 0.0000
S 447 315.750000 11615.6900 11615.6900
H 0 0.000000 0.0000 0.0000
T 3342 27270.447431 42705.0923 42705.0900
15199 19008.877600 272773.9500 17884.2500
Other 18 17.250000 859.2500 0.0000
---------------------------------------------------------
Total 22952 50302.000031 494123.8723 230621.0300
Center 54
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 2 1.500000 68.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 3797 3006.000000 124176.2500 0.0000
P 2549 2236.000000 104403.0000 104408.2500
D 1 0.250000 9.2500 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 7877 50296.750000 105944.3400 105944.3400
18247 30139.250000 347159.2400 0.0000
Other 1 0.750000 27.7500 0.0000
---------------------------------------------------------
Total 32474 85680.500000 681788.3300 210352.5900
Center 55
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 2 3.750000 138.7500 0.0000
P 10291 12092.060154 294061.5300 293575.8300
D 14 28.000000 2100.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 1 2.000000 150.0000 0.0000
T 4080 5253.546958 104333.6000 104333.6000
8904 6865.535051 351611.4248 29899.1000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 23292 24244.892163 752395.3048 427808.5300
Center 57
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 32 29.750000 1100.7500 0.0000
U 0 0.000000 0.0000 0.0000
B 2286 2188.500000 85959.0000 0.0000
P 831 795.750000 32939.9400 32939.9400
D 21 12.500000 462.5000 0.0000
S 120 1147.750000 7671.2700 7671.2700
H 2 0.500000 18.5000 0.0000
T 3269 22768.250000 229375.7100 229298.5900
4846 8147.750000 393979.7200 286028.7200
Other 29 88.000000 1815.0000 1815.0000
---------------------------------------------------------
Total 11436 35178.750000 753322.3900 557753.5200