CMS/EIP Fiscal Report Statewide
Services beginning 04/01/2017 ending 06/30/2017 Date of Report:08/05/2017 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 11341 12634.75000 467340.7500 36.9885
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 8897 13760.00000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 21784 68294.75000 2524884.0000 36.9704
Subtotal (Total Children Is Unduplicated) 22870 94689.50000 2992224.7500 31.6004
-----------------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
AACIS-92597-AAC INTIAL EVAL BY LICENSED SLP 1 1.000000 102.6300 102.6300
ASTE-ASTE-ASSISTIVE TECHNOLOGY EVAL 21 21.000000 1018.5000 48.5000
AUDE-92552-PURE TONE AUDIOMETRY -AIR ONLY 84 87.000000 1541.1200 17.7140
AUDE-92553-PURE TONE AUDIOMETRY AIR & BONE 3 3.000000 64.0500 21.3500
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 89 91.000000 1147.5100 12.6100
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 100 103.000000 842.5200 8.1798
AUDE-92568-ACOUSTIC REFLEX TESTING (MEMR) 1 1.000000 9.0600 9.0600
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 102 104.000000 2632.2400 25.3100
AUDE-92585-AUD EVOKED RESPONSE (COMP) 1 1.000000 77.1300 77.1300
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 56 56.000000 1038.8000 18.5500
AUDE-92588-OTOACOUSTIC EMISSIONS (COMP) 7 7.000000 144.7600 20.6800
AUDE-V5010-ASSESSMENT FOR HEARING AID 3 3.000000 135.0000 45.0000
AUDE-V5090-DISPENSING FEE PER HEARING AID 6 9.000000 1035.0000 115.0000
BEHV-H0031HO-COMP BEHAVIORAL HEALTH ASSESSMENT 1 1.000000 125.0000 125.0000
EVAL-96111-DEVELOPMENTAL EVALUATION 83 101.250000 5062.5000 50.0000
EXIT-EXIT-EXIT ASSESSMENT 794 1334.500000 64990.5700 48.7003
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 159 274.500000 20196.1200 73.5742
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 78 160.000000 11830.0000 73.9375
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 37 54.500000 4087.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 127 215.500000 16168.7700 75.0291
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 197 337.500000 18731.2500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 1894 2901.000003 216627.3306 74.6733
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 847 1288.500000 96392.5025 74.8099
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 613 950.000000 71135.0000 74.8789
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 2436 3841.500000 212484.5600 55.3129
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 1295 1997.500821 150532.1523 75.3602
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 61 61.000000 6271.9500 102.8189
MED-99204-OUTPATIENT VISIT, NEW, 45 MINS 1 1.000000 75.7200 75.7200
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 9 9.000000 405.8800 45.0978
NUTR-97802-NUTRITIONAL EVAL, INITIAL 2 3.000000 150.0000 50.0000
NUTR-97803-NUTRITIONAL EVAL, FOLLOW-UP 35 158.000000 7900.0000 50.0000
OCTF-97168-OT RE-EVAL EST PLAN CARE 14 14.000000 682.3000 48.7357
OCTH-97165-OT EVAL LOW COMPLEXITY 13 13.000000 630.5900 48.5069
OCTH-97166-OT EVAL MODERATE COMPLEXITY 39 39.000000 1990.9500 51.0500
OCTH-97167-OT EVAL HIGH COMPLEXITY 98 103.000000 5215.5800 50.6367
PSTF-97164-PT RE-EVAL EST PLAN CARE 14 14.000000 714.7000 51.0500
PSTH-97161-PT EVAL LOW COMPLEXITY 5 5.000000 250.2500 50.0500
PSTH-97162-PT EVAL MODERATE COMPLEXITY 22 24.000000 1153.3200 48.0550
PSTH-97163-PT EVAL HIGH COMPLEXITY 71 72.000000 3556.0800 49.3900
SCREEN-T1023-SCREENING 96 97.000000 4850.0000 50.0000
SENS-V5014TS-HEARING AID REPAIR IN-OFFICE 1 1.000000 15.0000 15.0000
SPCH-92521-EVAL OF SPEECH FLUENCY 1 1.000000 51.0500 51.0500
SPCH-92522-EVAL OF SPCH SOUND PROD 1 1.000000 51.0500 51.0500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 217 221.000000 11132.8100 50.3747
SPCH-92524-BEHAV & QUAL ANALYSIS OF
VOICE AND RES 28 28.000000 1429.4000 51.0500
Subtotal (Total Children Is Unduplicated) 5283 14809.25082 944678.2054 63.7897
-----------------------------------------------------------------------------------------------------------------------
EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 44 92.000000 22285.7100 242.2360
AUD-92593TS-AUDIOLOGY SERVICES (Biaural) 2 2.000000 83.8700 41.9350
AUDE-V5160-DISPENSING FEE BINAURAL 2 2.000000 460.0000 230.0000
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 1476 1752.250000 87337.5000 49.8431
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 88 69.000000 1725.0000 25.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 2142 3761.500000 187906.0000 49.9551
CONIP-CONIP-CONSULT, ITDS PHONE 216 192.000000 4793.7500 24.9674
CONOF-CONOF-CONSULT, OT, FACE TO FACE 463 739.250000 36962.5000 50.0000
CONOP-CONOP-CONSULT, OT, PHONE 26 40.750000 1018.7500 25.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 363 401.750000 20012.5000 49.8133
CONPP-CONPP-CONSULT, PT, PHONE 9 5.000000 125.0000 25.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 1197 1451.250000 72562.5000 50.0000
CONSP-CONSP-CONSULT, SLP, PHONE 94 93.250000 2331.2500 25.0000
COUN-H2019HR-INDIVIDUAL/FAMILY THERAPY 12 32.000000 2346.2400 73.3200
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 124 4750.750000 118768.7500 25.0000
EIIF-96154-HEALTH AND BEHAVIOR INTERVENTION 4 170.250000 8512.5000 50.0000
EIIF-EIIF_NM-EI INDIVIDUAL SESSION BY NONMED PROF 17 116.000000 5800.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 9180 70550.25000 3515674.0600 49.8322
INTR-T1013-INTERPRETER 447 1748.750000 81604.1300 46.6643
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 13115 201013.5000 1171947.9800 5.8302
OCCT-97530-OT SESSION BY LICENSED OT 1030 5670.250700 393237.2084 69.3509
OCCT-97530HM-OT SESSION BY OT ASST 327 1877.220282 107141.6401 57.0746
PHY-97110-PT SESSION BY LICENSED PT 1095 6066.818849 416690.3918 68.6835
PHY-97110HM-PT SESSION BY PT ASST 140 874.250000 49714.2600 56.8650
SENS-V5014-*HEARING AID REPAIR BY MANUFACTURER 1 2.000000 228.0000 114.0000
CMS/EIP Fiscal Report Statewide
Services beginning 04/01/2017 ending 06/30/2017 Date of Report:08/05/2017 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-V5050-IN EAR MONAURAL HEARING AID 4 7.000000 1596.0000 228.0000
SENS-V5140-BEHIND EAR BINAURAL HEARING AID
3 3.000000 1368.0000 456.0000
SENS-V5264-EARMOLD 15 26.000000 468.0000 18.0000
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 2397 16209.34086 1138356.9871 70.2285
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 12 86.000000 4633.2000 53.8744
SPL-92508-GROUP SPL SESSION PER CHILD 27 139.250000 2055.1900 14.7590
TRAV-TRAVS-Travel by mile 5584 554706.0000 244782.7300 0.4413
Subtotal (Total Children Is Unduplicated) 15847 872650.6307 7702529.5974 8.8266
-----------------------------------------------------------------------------------------------------------------------
Total 982149.381515 11639432.5528 11.8510
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 24527
-----------------------------------------------------------------------------------------------------------------------
Center 01
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 87 77.500000 3487.4200 0.0000
U 0 0.000000 0.0000 0.0000
B 8195 5565.000000 220160.8000 0.0000
P 19979 83570.500000 375552.0900 375552.0900
D 828 3819.750000 22721.1400 0.0000
S 557 436.500000 16122.7500 0.0000
H 76 95.000000 6667.3500 0.0000
T 2402 8045.500000 57973.3800 57769.8800
6476 4401.500000 131926.6400 0.0000
Other 77 118.000000 7866.7500 0.0000
---------------------------------------------------------
Total 38677 106129.250000 842478.3200 433321.9700
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 1 0.500000 18.5000 0.0000
D 0 0.000000 0.0000 0.0000
S 2 2.000000 60.2200 0.0000
H 0 0.000000 0.0000 0.0000
T 5150 11168.000000 127584.7000 127932.2300
151 136.750000 6813.7700 0.0000
Other 5257 16138.250000 116611.0900 99.0000
---------------------------------------------------------
Total 10561 27445.500000 251088.2800 128031.2300
Center 03
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 1441 853.500000 32863.2500 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 0 0.000000 0.0000 0.0000
16815 75134.750000 346834.6000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 18256 75988.250000 379697.8500 0.0000
Center 04
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 1 2.750000 101.7500 0.0000
U 0 0.000000 0.0000 0.0000
B 3043 4586.000000 172648.2500 0.0000
P 5313 18001.250000 374257.5500 374275.1200
D 10 10.750000 397.7500 0.0000
S 2 1.750000 64.7500 0.0000
H 2737 11093.000000 561523.4700 733.6600
T 0 0.000000 0.0000 0.0000
4058 7887.750000 278252.9200 0.0000
Other 82 186.500000 12583.7600 1125.2200
---------------------------------------------------------
Total 15246 41769.750000 1399830.2000 376134.0000
Center 05
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 10 6.000000 222.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 2598 1706.250000 67848.7500 0.0000
P 5538 63870.500000 176290.6900 175891.2400
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
2653 1539.500000 43590.2300 346.4800
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 10799 67122.250000 287951.6700 176237.7200
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 8331 7973.000000 180528.1700 180528.1700
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
18774 13626.500000 434659.1200 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 27105 21599.500000 615187.2900 180528.1700
Center 07
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 22 18.250000 675.2500 0.0000
P 10018 15614.000000 425780.5900 425771.3400
D 164 91.750000 3526.2500 0.0000
S 2 0.750000 27.7500 0.0000
H 0 0.000000 0.0000 0.0000
T 3 1.500000 55.5000 0.0000
7197 4594.250000 132118.2700 0.0000
Other 3 3.000000 111.0000 0.0000
---------------------------------------------------------
Total 17409 20323.500000 562294.6100 425771.3400
Center 09
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 2 3.000000 225.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 54 59.000000 2992.7500 0.0000
P 20810 157330.500000 867324.6100 869885.2190
D 7 10.000000 633.0000 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
2847 11140.000000 462596.3200 0.0000
Other 154 230.000000 16938.0000 0.0000
---------------------------------------------------------
Total 23874 168772.500000 1350709.6800 869885.2190
Center 10
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 10 4.500000 166.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 10031 7731.750000 323570.2500 0.0000
P 10290 30177.500000 758093.1100 758083.8600
D 0 0.000000 0.0000 0.0000
S 3 3.500000 224.5000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
10033 17409.250000 817794.9500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 30367 55326.500000 1899849.3100 758083.8600
Center 51
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 2341 1454.000000 56921.7500 0.0000
P 1984 90704.500000 183615.9500 183625.9500
D 32 15.000000 573.5000 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
4356 5174.250000 247353.1100 10.0000
Other 1 1.000000 10.0000 10.0000
---------------------------------------------------------
Total 8714 97348.750000 488474.3100 183645.9500
Center 52
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 353 361.500000 17895.2500 114.7500
P 2914 2552.250000 116601.8400 116254.6800
D 94 111.750000 5894.0300 0.0000
S 5 7.000000 450.0000 0.0000
H 339 363.000000 24502.8900 0.0000
T 7387 61660.500000 272167.8900 260391.4600
4219 5367.250000 177683.6900 10421.7800
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 15311 70423.250000 615195.5900 387182.6700
Center 53
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 1 0.500000 18.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 427 347.500000 14617.5000 1387.5000
P 3909 3733.950000 168488.0000 167638.2500
D 10 12.000000 661.0000 0.0000
S 3 2.500000 118.5000 18.5000
H 0 0.000000 0.0000 0.0000
T 6003 46545.651622 68526.6167 68526.6200
14943 12116.899199 301749.8056 0.0000
Other 31 26.750000 1272.7500 0.0000
---------------------------------------------------------
Total 25327 62785.750821 555452.6723 237570.8700
Center 54
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 2843 2283.750000 98674.0000 0.0000
P 26 23.500000 1176.5000 1158.0000
D 0 0.000000 0.0000 0.0000
S 2 2.250000 83.2500 0.0000
H 0 0.000000 0.0000 0.0000
T 12788 80771.350000 164724.2500 164724.2500
19568 16266.240000 471274.5800 0.0000
Other 4 1.250000 46.2500 0.0000
---------------------------------------------------------
Total 35231 99348.340000 735978.8300 165882.2500
Center 55
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 4 6.000000 374.0000 0.0000
P 15305 21654.516348 422234.2017 422123.3900
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 7 14.000000 1000.0000 0.0000
T 0 0.000000 0.0000 0.0000
9074 7180.774346 377836.5288 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 24390 28855.290694 801444.7305 422123.3900
Center 57
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 1 2.500000 92.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 1301 1268.750000 48950.0000 0.0000
P 2059 1995.773900 84552.2600 84552.2600
D 27 22.000000 814.0000 0.0000
S 128 262.226100 6633.9100 6673.9100
H 0 0.000000 0.0000 0.0000
T 4132 26564.750000 297919.3300 297817.8700
4609 8576.250000 408068.2200 309110.2200
Other 38 69.500000 1653.7400 1653.7400
---------------------------------------------------------
Total 12295 38761.750000 848683.9600 699808.0000