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: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 12091 13009.25000 481200.2500 36.9891
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 9344 14154.00000 521.4400 0.0368
TCM-T1017TL-TARGETED CASE MANAGEMENT 22812 72515.50000 2681526.0900 36.9787
Subtotal (Total Children Is Unduplicated) 23828 99678.75000 3163247.7800 31.7344
-----------------------------------------------------------------------------------------------------------------------
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 180 317.500000 14626.5200 46.0678
EXIT-EXIT-EXIT ASSESSMENT 736 1169.000000 58450.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 170 268.500000 19915.6000 74.1736
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 84 158.000000 11762.3400 74.4452
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 48 63.500000 4762.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 151 238.500000 17705.1400 74.2354
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 229 380.500000 21052.7500 55.3292
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 2532 3938.000196 292773.5296 74.3457
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 1010 1493.500600 110587.9000 74.0461
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 824 1210.500200 90378.3700 74.6620
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 3017 4596.500000 254355.4700 55.3368
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 1717 2569.500031 192760.6423 75.0187
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 94 94.000000 8395.1300 89.3099
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 113 123.000000 6150.0000 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) 6438 17588.50103 1146497.6519 65.1845
-----------------------------------------------------------------------------------------------------------------------
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 1315 1568.000000 75875.0000 48.3897
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 60 52.500000 1312.5000 25.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 2026 3456.250000 172562.5000 49.9277
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 8778 63170.25000 3157341.9500 49.9815
INTR-T1013-INTERPRETER 449 1522.300000 72580.2900 47.6780
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 12427 101579.0000 1019559.4520 10.0371
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 1153 6905.293600 532000.7151 77.0424
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:Program Patients
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 5360 488209.0000 215637.0700 0.4417
Subtotal (Total Children Is Unduplicated) 15453 699752.6916 7280098.3171 10.4038
-----------------------------------------------------------------------------------------------------------------------
Total 817019.942593 11589843.7490 14.1855
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 25286
-----------------------------------------------------------------------------------------------------------------------
Center 01
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 86 73.000000 4689.9400 0.0000
U 0 0.000000 0.0000 0.0000
B 8759 5763.250000 219969.0200 0.0000
P 16103 68012.000000 294771.0720 294771.0700
D 1749 7057.750000 51302.0800 0.0000
S 505 561.000000 36411.0800 0.0000
H 124 153.750000 11058.1000 0.0000
T 1905 8756.500000 35242.6600 35084.2100
6921 4605.750000 140022.5500 88.0200
Other 1 1.000000 71.4400 0.0000
---------------------------------------------------------
Total 36153 94984.000000 793537.9420 329943.3000
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 4648 9028.750000 143587.5800 142263.2940
404 447.250000 8088.9100 0.0000
Other 5655 15719.250000 126434.7800 0.0000
---------------------------------------------------------
Total 10707 25195.250000 278111.2700 142263.2940
Center 03
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 1069 692.250000 27117.5000 100.0000
P 2329 1520.000000 63376.5000 46551.2750
D 18 10.500000 388.5000 0.0000
S 6 5.250000 194.2500 0.0000
H 213 204.750000 48890.4900 0.0000
T 0 0.000000 0.0000 0.0000
13767 46030.500000 305564.1900 0.0000
Other 71 56.000000 2215.0000 0.0000
---------------------------------------------------------
Total 17473 48519.250000 447746.4300 46651.2750
Center 04
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 1 1.000000 55.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 795 998.750000 44354.7500 0.0000
P 6841 18223.750000 439057.0000 439021.5100
D 83 108.250000 4042.7500 0.0000
S 2 2.000000 74.0000 0.0000
H 2275 8931.500000 449930.2000 348.6400
T 0 0.000000 0.0000 0.0000
5064 10409.750000 365577.2400 0.0000
Other 65 153.500000 9754.3600 3520.3300
---------------------------------------------------------
Total 15126 38828.500000 1312845.8000 442890.4800
Center 05
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 1 1.000000 37.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 3086 2137.500000 87294.0000 0.0000
P 4804 59910.050000 169456.5500 169566.4780
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
3013 1811.500000 49446.8700 283.1200
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 10904 63860.050000 306234.4200 169849.5980
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 10726 10169.500000 228939.6500 228939.6500
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
19568 14139.250000 584622.3200 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 30294 24308.750000 813561.9700 228939.6500
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 11485 16693.250000 450472.7400 450417.2400
D 132 91.250000 3667.2500 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
7694 4902.500000 147610.5500 0.0000
Other 1 1.000000 37.0000 0.0000
---------------------------------------------------------
Total 19330 21699.250000 602203.7900 450417.2400
Center 09
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 2 3.500000 129.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 229 209.250000 8238.2500 27.7500
P 19705 154184.000000 885242.3100 885400.7100
D 8 11.000000 726.5700 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 1 0.750000 27.7500 27.7500
3008 11887.250000 460083.0300 276.4600
Other 207 301.000000 22316.0000 0.0000
---------------------------------------------------------
Total 23160 166596.750000 1376763.4100 885732.6700
Center 10
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 548 383.500000 14189.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 7466 5617.750000 239538.0000 0.0000
P 10495 26968.500000 720398.3200 720066.8800
D 102 66.500000 2460.5000 0.0000
S 70 41.000000 1669.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
9308 14908.750000 756360.5600 60.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 27989 47986.000000 1734615.8800 720126.8800
Center 51
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 6 6.500000 278.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 2431 1561.000000 60814.0000 0.0000
P 1880 5860.750000 176688.8100 176688.8000
D 9 4.000000 148.0000 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
4822 5123.750000 240237.6500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 9148 12556.000000 478166.9600 176688.8000
Center 52
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 287 207.500000 8593.7500 37.0000
P 3211 2969.500000 139265.9600 135540.1000
D 87 103.250000 6584.2400 0.0000
S 6 6.000000 222.0000 0.0000
H 94 96.500000 6328.6200 46.9000
T 7297 63835.750000 278712.6900 267723.0400
4475 4648.250000 184396.4900 2694.2300
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 15457 71866.750000 624103.7500 406041.2700
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 4103 3857.675000 173491.1400 172529.5000
D 3 3.000000 150.0000 0.0000
S 476 344.500000 12679.4400 12623.9400
H 0 0.000000 0.0000 0.0000
T 3359 27487.447431 42887.6823 42887.6800
15807 19710.627600 285306.1100 19151.5000
Other 18 17.250000 859.2500 0.0000
---------------------------------------------------------
Total 23899 51557.750031 522015.8723 247192.6200
Center 54
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 2 1.500000 68.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 4191 3395.750000 140500.7500 0.0000
P 2742 2454.750000 115318.0000 115323.2500
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 7977 51044.250000 107442.0600 107442.0600
19024 30999.250000 364172.1900 0.0000
Other 1 0.750000 27.7500 0.0000
---------------------------------------------------------
Total 33938 87896.500000 727538.5000 222765.3100
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 10683 12621.462121 318578.7400 317839.4900
D 21 42.000000 3150.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 2 4.000000 300.0000 0.0000
T 4095 5283.184458 106439.4100 106439.4100
9379 7340.995983 372747.6547 34077.4000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 24182 25295.392562 801354.5547 458356.3000
Center 57
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 32 29.750000 1100.7500 0.0000
U 0 0.000000 0.0000 0.0000
B 2388 2322.000000 91389.0000 0.0000
P 879 848.000000 35448.4400 35448.4400
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 3277 23064.250000 229564.7700 229487.6500
5020 8357.000000 403572.9700 286756.2200
Other 29 88.000000 1815.0000 1815.0000
---------------------------------------------------------
Total 11768 35869.750000 771043.2000 561178.5800