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
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 11288 12225.25000 452192.2500 36.9884
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 8559 12983.25000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 7070 22285.50000 824196.4000 36.9835
Subtotal (Total Children Is Unduplicated) 17189 47494.00000 1276388.6500 26.8747
-----------------------------------------------------------------------------------------------------------------------
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) 49 49.000000 404.7400 8.2600
AUDE-92568-ACOUSTIC REFLEX TESTING (MEMR) 4 4.000000 36.2400 9.0600
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 47 47.000000 1186.1000 25.2362
AUDE-92585-AUD EVOKED RESPONSE (COMP) 1 1.000000 77.1300 77.1300
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 22 22.000000 412.1400 18.7336
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 119 184.592600 9229.6300 50.0000
EXIT-EXIT-EXIT ASSESSMENT 734 1167.000000 58350.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 33 46.262000 3310.2500 71.5544
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 30 44.000000 3267.3400 74.2577
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 6 8.000000 600.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 27 35.500000 2510.0200 70.7048
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 71 84.500000 4624.7500 54.7308
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 491 736.557496 53738.2297 72.9586
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 149 226.721300 15736.2300 69.4078
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 173 252.266700 18648.1000 73.9222
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 716 896.500000 49251.2000 54.9372
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 358 526.081231 38717.9023 73.5968
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 33 33.000000 1584.4500 48.0136
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 5 5.000000 119.6400 23.9280
OCTF-97168-OT RE-EVAL EST PLAN CARE 5 5.000000 255.2500 51.0500
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 3 3.000000 153.1500 51.0500
OCTH-97165-OT EVAL LOW COMPLEXITY 10 10.000000 485.5000 48.5500
OCTH-97166-OT EVAL MODERATE COMPLEXITY 31 31.000000 1582.5500 51.0500
OCTH-97167-OT EVAL HIGH COMPLEXITY 44 44.000000 2246.2000 51.0500
PSTF-97164-PT RE-EVAL EST PLAN CARE 2 2.000000 102.1000 51.0500
PSTH-97001-EVAL BY LICENSED PT, INITIAL 1 1.000000 51.0500 51.0500
PSTH-97161-PT EVAL LOW COMPLEXITY 5 5.000000 255.2500 51.0500
PSTH-97162-PT EVAL MODERATE COMPLEXITY 14 14.000000 714.7000 51.0500
PSTH-97163-PT EVAL HIGH COMPLEXITY 27 28.000000 1379.4000 49.2643
SCREEN-T1023-SCREENING 19 25.000000 1250.0000 50.0000
SPCH-92521-EVAL OF SPEECH FLUENCY 3 3.000000 153.1500 51.0500
SPCH-92522-EVAL OF SPCH SOUND PROD 2 2.000000 102.1000 51.0500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 172 174.000000 8808.5700 50.6240
SPCH-92524-BEHAV & QUAL ANALYSIS OF
VOICE AND RES 6 6.000000 306.3000 51.0500
Subtotal (Total Children Is Unduplicated) 2456 4844.981327 283228.8620 58.4582
-----------------------------------------------------------------------------------------------------------------------
EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 50 106.000000 33894.1000 319.7557
AUDE-V5160-DISPENSING FEE BINAURAL 1 1.000000 230.0000 230.0000
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 1284 1519.250000 73437.5000 48.3380
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 52 43.750000 1093.7500 25.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 2007 3406.500000 170075.0000 49.9266
CONIP-CONIP-CONSULT, ITDS PHONE 201 163.750000 4059.0000 24.7878
CONOF-CONOF-CONSULT, OT, FACE TO FACE 444 674.000000 33700.0000 50.0000
CONOP-CONOP-CONSULT, OT, PHONE 31 30.000000 750.0000 25.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 346 461.500000 22825.0000 49.4583
CONPP-CONPP-CONSULT, PT, PHONE 6 4.250000 106.2500 25.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 1006 1210.750000 60537.5000 50.0000
CONSP-CONSP-CONSULT, SLP, PHONE 94 80.000000 2000.0000 25.0000
COUN-H2019HR-INDIVIDUAL/FAMILY THERAPY 10 41.000000 3006.1200 73.3200
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 32 142.750000 3568.7500 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 2905 19470.44120 972724.5100 49.9590
INTR-T1013-INTERPRETER 421 1473.050000 70146.2900 47.6198
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 12173 101030.0000 1014345.8420 10.0400
OCCT-97530-OT SESSION BY LICENSED OT 603 3001.194263 207680.5300 69.1993
OCCT-97530HM-OT SESSION BY OT ASST 150 710.972858 40641.4700 57.1632
PHY-97110-PT SESSION BY LICENSED PT 679 3478.343993 238546.4900 68.5805
PHY-97110HM-PT SESSION BY PT ASST 46 249.974300 14165.2600 56.6669
SENS-V5050-IN EAR MONAURAL HEARING AID 3 6.000000 1912.0000 318.6667
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 1594 9758.907998 681604.7600 69.8444
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 10 43.000000 2459.6000 57.2000
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
Payclass Filters:GR
Eligibility Filter:Part C (excluding not eligible)
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
SPL-92508-GROUP SPL SESSION PER CHILD 5 9.000000 124.9200 13.8800
TRAV-TRAVS-Travel by mile 4978 438185.0000 193534.0300 0.4417
Subtotal (Total Children Is Unduplicated) 14410 585551.3846 3859804.6720 6.5917
-----------------------------------------------------------------------------------------------------------------------
Total 637890.365939 5419422.1840 8.4959
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 21237
-----------------------------------------------------------------------------------------------------------------------
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 15873 66984.250000 282336.0120 282336.0100
D 1377 6626.000000 28989.9800 0.0000
S 52 53.250000 1493.3400 0.0000
H 0 0.000000 0.0000 0.0000
T 1854 8669.500000 32233.6100 32075.1600
6452 4228.250000 127453.6500 88.0200
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 25608 86561.250000 472506.5920 314499.1900
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
397 376.000000 7632.2500 0.0000
Other 3353 12683.250000 52991.9700 0.0000
---------------------------------------------------------
Total 8363 21676.000000 202973.7600 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 0 0.000000 0.0000 0.0000
P 0 0.000000 0.0000 0.0000
D 18 10.500000 388.5000 0.0000
S 0 0.000000 0.0000 0.0000
H 2 1.500000 71.4400 0.0000
T 0 0.000000 0.0000 0.0000
13052 45161.750000 263392.8500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 13072 45173.750000 263852.7900 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 3370 13001.750000 231596.6800 231596.6800
D 83 108.250000 4042.7500 0.0000
S 0 0.000000 0.0000 0.0000
H 15 50.500000 975.7200 120.0000
T 0 0.000000 0.0000 0.0000
3481 3132.250000 127079.8900 0.0000
Other 19 44.000000 2555.5700 1595.1800
---------------------------------------------------------
Total 6968 16336.750000 366250.6100 233311.8600
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 4689 58886.050000 164608.1200 164697.6580
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 7426 60515.550000 209244.9900 164980.7780
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 10709 10158.000000 228169.8500 228169.8500
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
8852 5364.750000 156197.7700 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 19561 15522.750000 384367.6200 228169.8500
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 5361 11927.750000 254163.0200 254153.7700
D 131 89.000000 3584.0000 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
6912 4148.500000 125352.5000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 12404 16165.250000 383099.5200 254153.7700
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 12917 104097.000000 542960.1500 542960.1500
D 1 1.000000 71.4400 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
465 4339.750000 26782.1700 92.5000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 13383 108437.750000 569813.7600 543052.6500
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 8631 25564.750000 655964.5700 655633.1300
D 101 66.250000 2451.2500 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
5713 4014.250000 121695.7500 60.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 14445 29645.250000 780111.5700 655693.1300
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 1861 5833.750000 175176.9700 175176.9600
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
3836 2588.000000 92284.1900 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 5697 8421.750000 267461.1600 175176.9600
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 1 1.000000 37.0000 37.0000
D 4 8.000000 600.0000 0.0000
S 1 0.250000 9.2500 0.0000
H 1 1.000000 50.0000 0.0000
T 7161 62630.750000 271086.9000 260596.4500
3178 2123.000000 49597.0000 173.2500
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 10346 64764.000000 321380.1500 260806.7000
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 27 27.000000 1396.6400 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 3338 27265.447431 42405.0923 42405.0900
13176 16910.075000 164361.5500 17246.7500
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 16541 44202.522431 208163.2823 59651.8400
Center 54
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 1 1.500000 83.2500 0.0000
P 0 0.000000 0.0000 0.0000
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 7861 50286.750000 105574.3400 105574.3400
15144 26785.750000 180798.3400 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 23007 77074.250000 286465.1800 105574.3400
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 6684 8941.465154 165829.5800 165829.5800
D 14 28.000000 2100.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 4080 5253.546958 104333.6000 104333.6000
4192 2597.031396 88283.7797 29899.1000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 14970 16820.043508 360546.9597 300062.2800
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 21 12.500000 462.5000 0.0000
S 119 1146.750000 7621.2700 7621.2700
H 0 0.000000 0.0000 0.0000
T 3265 22755.750000 228568.4700 228491.3500
2943 2658.500000 106532.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 6348 26573.500000 343184.2400 236112.6200