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
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 11340 12634.50000 467331.5000 36.9885
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 8854 13603.00000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 7137 22094.25000 816488.0000 36.9548
Subtotal (Total Children Is Unduplicated) 17706 48331.75000 1283819.5000 26.5627
-----------------------------------------------------------------------------------------------------------------------
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 86.000000 1526.2500 17.7471
AUDE-92553-PURE TONE AUDIOMETRY AIR & BONE 3 3.000000 64.0500 21.3500
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 87 89.000000 1122.2900 12.6100
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 89 91.000000 751.4700 8.2579
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 91 93.000000 2353.8300 25.3100
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 52 52.000000 964.6000 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 81 97.250000 4862.5000 50.0000
EXIT-EXIT-EXIT ASSESSMENT 793 1333.500000 64940.5700 48.6993
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 37 47.000000 3513.6200 74.7579
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 24 23.500000 1762.5000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 8 11.000000 825.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 25 51.000000 3825.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 46 59.500000 3302.2500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 379 507.568095 37704.4975 74.2846
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 123 176.621600 13206.6225 74.7735
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 123 175.600000 13132.5000 74.7864
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 589 749.000000 41460.7500 55.3548
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 272 411.751822 30762.0667 74.7102
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 24 24.000000 1285.2000 53.5500
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 6 6.000000 159.6600 26.6100
NUTR-97802-NUTRITIONAL EVAL, INITIAL 1 1.000000 50.0000 50.0000
NUTR-97803-NUTRITIONAL EVAL, FOLLOW-UP 20 89.000000 4450.0000 50.0000
OCTF-97168-OT RE-EVAL EST PLAN CARE 7 7.000000 324.9500 46.4214
OCTH-97165-OT EVAL LOW COMPLEXITY 4 4.000000 171.1400 42.7850
OCTH-97166-OT EVAL MODERATE COMPLEXITY 23 23.000000 1174.1500 51.0500
OCTH-97167-OT EVAL HIGH COMPLEXITY 42 41.456024 2080.5700 50.1874
PSTF-97164-PT RE-EVAL EST PLAN CARE 5 5.000000 255.2500 51.0500
PSTH-97161-PT EVAL LOW COMPLEXITY 4 4.000000 199.2000 49.8000
PSTH-97162-PT EVAL MODERATE COMPLEXITY 9 8.155142 416.3200 51.0500
PSTH-97163-PT EVAL HIGH COMPLEXITY 22 22.000000 1003.5800 45.6173
SCREEN-T1023-SCREENING 9 9.000000 450.0000 50.0000
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 115 117.000000 5893.5700 50.3724
SPCH-92524-BEHAV & QUAL ANALYSIS OF
VOICE AND RES 8 8.000000 408.4000 51.0500
Subtotal (Total Children Is Unduplicated) 2198 4467.902683 246963.2467 55.2750
-----------------------------------------------------------------------------------------------------------------------
EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 37 63.000000 16130.7600 256.0438
AUD-92593TS-AUDIOLOGY SERVICES (Biaural) 1 1.000000 33.8700 33.8700
AUDE-V5160-DISPENSING FEE BINAURAL 1 1.000000 230.0000 230.0000
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 1464 1729.500000 86200.0000 49.8410
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 87 68.000000 1700.0000 25.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 2137 3751.000000 187381.0000 49.9549
CONIP-CONIP-CONSULT, ITDS PHONE 216 192.000000 4793.7500 24.9674
CONOF-CONOF-CONSULT, OT, FACE TO FACE 459 728.500000 36425.0000 50.0000
CONOP-CONOP-CONSULT, OT, PHONE 25 40.250000 1006.2500 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 1195 1445.250000 72262.5000 50.0000
CONSP-CONSP-CONSULT, SLP, PHONE 94 93.250000 2331.2500 25.0000
COUN-H2019HR-INDIVIDUAL/FAMILY THERAPY 9 17.000000 1246.4400 73.3200
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 49 207.250000 5181.2500 25.0000
EIIF-96154-HEALTH AND BEHAVIOR INTERVENTION 2 51.250000 2562.5000 50.0000
EIIF-EIIF_NM-EI INDIVIDUAL SESSION BY NONMED PROF 15 101.500000 5075.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 2974 21430.75000 1060181.4600 49.4701
INTR-T1013-INTERPRETER 447 1748.750000 81604.1300 46.6643
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 13108 200863.5000 1170447.9800 5.8271
OCCT-97530-OT SESSION BY LICENSED OT 547 2692.797191 185761.8370 68.9847
OCCT-97530HM-OT SESSION BY OT ASST 104 489.560104 27999.2101 57.1926
PHY-97110-PT SESSION BY LICENSED PT 601 2953.226298 201689.8736 68.2948
PHY-97110HM-PT SESSION BY PT ASST 49 317.429800 18144.2900 57.1600
SENS-V5014-*HEARING AID REPAIR BY MANUFACTURER 1 2.000000 228.0000 114.0000
SENS-V5050-IN EAR MONAURAL HEARING AID 3 6.000000 1368.0000 228.0000
SENS-V5140-BEHIND EAR BINAURAL HEARING AID
2 2.000000 912.0000 456.0000
SENS-V5264-EARMOLD 7 12.000000 216.0000 18.0000
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 1376 8393.218349 588721.3810 70.1425
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 5 25.000000 1430.0000 57.2000
SPL-92508-GROUP SPL SESSION PER CHILD 16 111.000000 1663.0800 14.9827
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
Payclass Filters:GR
Eligibility Filter:Part C (excluding not eligible)
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
TRAV-TRAVS-Travel by mile 5545 546279.0000 241057.6300 0.4413
Subtotal (Total Children Is Unduplicated) 15373 794222.7317 4024121.9417 5.0667
-----------------------------------------------------------------------------------------------------------------------
Total 847022.384425 5554904.6884 6.5582
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 22111
-----------------------------------------------------------------------------------------------------------------------
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 18854 82417.750000 307167.1300 307167.1300
D 678 3663.750000 14280.4200 0.0000
S 18 11.000000 379.2500 0.0000
H 0 0.000000 0.0000 0.0000
T 2083 7724.000000 39472.9800 39445.2300
6416 4351.000000 129176.2200 0.0000
Other 1 1.000000 55.5000 0.0000
---------------------------------------------------------
Total 28050 98168.500000 490531.5000 346612.3600
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 0 0.000000 0.0000 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 3427 14774.500000 56921.8400 99.0000
---------------------------------------------------------
Total 8729 26079.750000 191338.8100 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 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 0 0.000000 0.0000 0.0000
15619 74418.500000 319976.6400 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 15619 74418.500000 319976.6400 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 3972 16079.000000 280853.7400 280853.7400
D 10 10.750000 397.7500 0.0000
S 0 0.000000 0.0000 0.0000
H 7 11.000000 345.8000 345.8000
T 0 0.000000 0.0000 0.0000
3304 2928.500000 118810.8100 0.0000
Other 12 23.000000 1394.4800 180.0000
---------------------------------------------------------
Total 7305 19052.250000 401802.5800 281379.5400
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 5442 63686.250000 163602.8200 163203.3700
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
2652 1539.250000 43580.9800 346.4800
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 8094 65225.500000 207183.8000 163549.8500
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 7486 7294.000000 142844.8700 142844.8700
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
12156 8512.250000 199586.2900 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 19642 15806.250000 342431.1600 142844.8700
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 4407 11041.250000 228119.2700 228119.2700
D 164 91.750000 3526.2500 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 1 0.500000 18.5000 0.0000
7100 4491.250000 127128.3900 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 11672 15624.750000 358792.4100 228119.2700
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 15435 147573.000000 631015.6000 631015.6000
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
46 220.500000 4133.7500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 15481 147793.500000 635149.3500 631015.6000
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 10289 30177.250000 758083.8600 758083.8600
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
6116 4536.250000 136532.5000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 16405 34713.500000 894616.3600 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 0 0.000000 0.0000 0.0000
P 1683 89622.750000 112846.3700 112856.3700
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
3465 2463.500000 86531.8500 10.0000
Other 1 1.000000 10.0000 10.0000
---------------------------------------------------------
Total 5149 92087.250000 199388.2200 112876.3700
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 3 2.250000 100.0000 100.0000
D 19 15.250000 679.2500 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 6945 60800.000000 223281.6900 216757.8100
2982 2056.000000 42288.9100 190.8600
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 9949 62873.500000 266349.8500 217048.6700
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 2 1.250000 59.2500 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 5935 46476.501822 65060.1367 65060.1400
11956 9047.500000 144797.6900 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 17893 55525.251822 209917.0767 65060.1400
Center 54
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 12663 80644.850000 157792.4000 157792.4000
12131 9207.000000 133303.0000 0.0000
Other 1 0.500000 18.5000 0.0000
---------------------------------------------------------
Total 24795 89852.350000 291113.9000 157792.4000
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 11302 18167.046304 269395.8117 269395.8200
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
3996 2540.236299 87299.8600 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 15298 20707.282603 356695.6717 269395.8200
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 27 22.000000 814.0000 0.0000
S 123 254.500000 6166.6700 6206.6700
H 0 0.000000 0.0000 0.0000
T 4010 26197.250000 277839.7500 277738.2900
2804 2512.750000 101209.7500 4540.0000
Other 2 2.000000 81.4400 81.4400
---------------------------------------------------------
Total 6966 28988.500000 386111.6100 288566.4000