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: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 12088 13008.50000 481172.5000 36.9891
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 9332 14076.25000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 7681 24490.00000 905744.4000 36.9843
Subtotal (Total Children Is Unduplicated) 18510 51574.75000 1386916.9000 26.8914
-----------------------------------------------------------------------------------------------------------------------
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 158 270.735600 13536.7800 50.0000
EXIT-EXIT-EXIT ASSESSMENT 735 1168.000000 58400.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 36 50.262000 3610.2500 71.8286
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 32 46.000000 3362.3400 73.0943
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 7 10.000000 750.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 34 46.500000 3305.1400 71.0783
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 80 98.500000 5401.7500 54.8401
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 651 975.535661 71091.5796 72.8744
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 204 305.610100 21587.8800 70.6386
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 229 326.904200 24176.7600 73.9567
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 918 1162.000000 63893.2000 54.9855
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 469 690.581231 50967.7923 73.8042
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 42 42.000000 2001.1500 47.6464
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 20 26.000000 1300.0000 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) 2857 5797.628792 345795.3819 59.6443
-----------------------------------------------------------------------------------------------------------------------
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 1285 1519.750000 73462.5000 48.3385
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 52 43.750000 1093.7500 25.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 2008 3408.500000 170175.0000 49.9267
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 2906 19476.94120 973049.5100 49.9591
INTR-T1013-INTERPRETER 449 1522.300000 72580.2900 47.6780
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 12426 101517.0000 1018939.4520 10.0371
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 680 3480.093993 238671.5100 68.5819
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:Program Patients
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 5178 444516.0000 196289.8300 0.4416
Subtotal (Total Children Is Unduplicated) 14770 592429.3846 3870163.1020 6.5327
-----------------------------------------------------------------------------------------------------------------------
Total 649801.763404 5602875.3839 8.6224
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 22608
-----------------------------------------------------------------------------------------------------------------------
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 15943 67843.500000 285043.6120 285043.6100
D 1383 6688.000000 29441.9600 0.0000
S 52 53.250000 1493.3400 0.0000
H 0 0.000000 0.0000 0.0000
T 1858 8707.500000 32358.4600 32200.0100
6870 4553.750000 137007.1500 88.0200
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 26106 87846.000000 485344.5220 317331.6400
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
401 444.500000 7933.2300 0.0000
Other 3606 14151.500000 56860.5300 0.0000
---------------------------------------------------------
Total 8655 23624.750000 208381.3400 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 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
13603 45629.250000 284229.8700 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 13623 45641.250000 284689.8100 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 3373 13014.750000 231726.6800 231726.6800
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
3921 3579.750000 145785.3400 0.0000
Other 19 44.000000 2555.5700 1595.1800
---------------------------------------------------------
Total 7411 16797.250000 385086.0600 233441.8600
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 4801 59905.050000 169119.7400 169209.2780
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 7814 61716.550000 218566.6100 169492.3980
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 10711 10162.000000 228403.8500 228403.8500
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
9272 5637.500000 165308.2700 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 19983 15799.500000 393712.1200 228403.8500
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 5421 12057.750000 256011.7500 256002.5000
D 132 91.250000 3667.2500 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
7639 4820.000000 143784.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 13192 16969.000000 403463.0000 256002.5000
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 13269 104524.250000 558144.7800 558144.7800
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
499 4383.000000 29060.2500 205.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 13769 108908.250000 587276.4700 558349.7800
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
6007 4319.000000 132446.2500 60.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 14739 29950.000000 790862.0700 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 1877 5849.750000 175902.9700 175902.9600
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
4037 2743.500000 97626.4400 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 5914 8593.250000 273529.4100 175902.9600
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 7238 63730.250000 272362.3600 261820.9100
3334 2252.000000 52250.0000 173.2500
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 10579 65992.500000 325308.6100 262031.1600
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 3355 27482.447431 42587.6823 42587.6800
13742 17551.075000 172897.2100 18514.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 17124 45060.522431 216881.5323 61101.6800
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 7960 51033.250000 107035.0600 107035.0600
15861 27550.750000 191988.5400 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 23823 78585.750000 299116.1000 107035.0600
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 6706 8978.117454 168157.4900 168157.4900
D 21 42.000000 3150.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 4095 5283.184458 106439.4100 106439.4100
4597 2951.139061 100988.2796 34077.4000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 15419 17254.440973 378735.1796 308674.3000
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 3273 23051.750000 228757.5300 228680.4100
3107 2851.750000 115081.2500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 6520 27062.750000 351922.5500 236301.6800