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:TPIN
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 1 0.250000 9.2500 37.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 5 5.250000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 26 55.000000 1979.5000 35.9909
Subtotal (Total Children Is Unduplicated) 32 60.500000 1988.7500 32.8719
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Screening, Eval, and Assessment,Class #02
AUDE-92552-PURE TONE AUDIOMETRY -AIR ONLY 1 1.000000 14.8700 14.8700
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 2 2.000000 25.2200 12.6100
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 12 12.000000 91.0500 7.5875
AUDE-92568-ACOUSTIC REFLEX TESTING (MEMR) 1 1.000000 9.0600 9.0600
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 11 11.000000 278.4100 25.3100
AUDE-92585-AUD EVOKED RESPONSE (COMP) 1 1.000000 77.1300 77.1300
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 4 4.000000 74.2000 18.5500
EVAL-96111-DEVELOPMENTAL EVALUATION 3 4.000000 200.0000 50.0000
EXIT-EXIT-EXIT ASSESSMENT 1 1.000000 50.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 23 45.500000 3032.5000 66.6484
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 8 19.000000 1255.0000 66.0526
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 6 9.500000 712.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 23 34.000000 2556.2700 75.1844
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 27 49.000000 2719.5000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 366 656.431908 48647.8331 74.1095
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 177 311.878400 23185.8800 74.3427
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 124 211.400000 15815.0000 74.8108
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 407 759.500000 41570.0600 54.7335
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 242 375.248999 29095.0856 77.5354
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 12 12.000000 3648.0000 304.0000
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 1 1.000000 193.0000 193.0000
NUTR-97802-NUTRITIONAL EVAL, INITIAL 1 2.000000 100.0000 50.0000
NUTR-97803-NUTRITIONAL EVAL, FOLLOW-UP 16 69.000000 3450.0000 50.0000
OCTF-97168-OT RE-EVAL EST PLAN CARE 1 1.000000 51.0500 51.0500
OCTH-97165-OT EVAL LOW COMPLEXITY 4 4.000000 204.2000 51.0500
OCTH-97166-OT EVAL MODERATE COMPLEXITY 9 9.000000 459.4500 51.0500
OCTH-97167-OT EVAL HIGH COMPLEXITY 30 29.543976 1501.4100 50.8195
PSTH-97161-PT EVAL LOW COMPLEXITY 1 1.000000 51.0500 51.0500
PSTH-97162-PT EVAL MODERATE COMPLEXITY 12 13.844858 634.9000 45.8582
PSTH-97163-PT EVAL HIGH COMPLEXITY 15 15.000000 765.7500 51.0500
SCREEN-T1023-SCREENING 13 13.000000 650.0000 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 69 70.000000 3503.5400 50.0506
SPCH-92524-BEHAV & QUAL ANALYSIS OF
VOICE AND RES 9 9.000000 459.4500 51.0500
Subtotal (Total Children Is Unduplicated) 964 2760.848141 185198.4687 67.0803
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 9 28.000000 5372.9100 191.8896
AUD-92593TS-AUDIOLOGY SERVICES (Biaural) 1 1.000000 50.0000 50.0000
AUDE-V5160-DISPENSING FEE BINAURAL 1 1.000000 230.0000 230.0000
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 1 1.000000 50.0000 50.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 1 0.500000 25.0000 50.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 1 1.000000 50.0000 50.0000
COUN-H2019HR-INDIVIDUAL/FAMILY THERAPY 2 5.000000 366.6000 73.3200
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 5 11.000000 275.0000 25.0000
EIIF-96154-HEALTH AND BEHAVIOR INTERVENTION 3 119.000000 5950.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 765 3959.000000 197690.6000 49.9345
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 2 2.000000 20.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 288 1260.203509 84851.9914 67.3320
OCCT-97530HM-OT SESSION BY OT ASST 112 601.410178 34222.1300 56.9031
PHY-97110-PT SESSION BY LICENSED PT 330 1502.342551 100140.9282 66.6565
PHY-97110HM-PT SESSION BY PT ASST 25 122.570200 6748.2400 55.0561
SENS-V5050-IN EAR MONAURAL HEARING AID 1 1.000000 228.0000 228.0000
SENS-V5140-BEHIND EAR BINAURAL HEARING AID
1 1.000000 456.0000 456.0000
SENS-V5264-EARMOLD 8 14.000000 252.0000 18.0000
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 767 4075.622511 282635.0661 69.3477
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 9 53.000000 2745.6000 51.8038
SPL-92508-GROUP SPL SESSION PER CHILD 5 7.500000 104.1000 13.8800
TRAV-TRAVS-Travel by mile 2 98.000000 43.6200 0.4451
Subtotal (Total Children Is Unduplicated) 1923 11865.14895 722507.7857 60.8933
-----------------------------------------------------------------------------------------------------------------------
Total 14686.497090 909695.0044 61.9409
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Number of Children (Unduplicated) With at Least One Service 2574
-----------------------------------------------------------------------------------------------------------------------
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 1108 1135.750000 66524.2000 66524.2000
D 77 84.000000 4429.4800 0.0000
S 0 0.000000 0.0000 0.0000
H 76 95.000000 6667.3500 0.0000
T 306 308.750000 17903.2100 17903.2100
25 30.000000 1934.9200 0.0000
Other 15 23.000000 1510.5000 0.0000
---------------------------------------------------------
Total 1607 1676.500000 98969.6600 84427.4100
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 2 2.000000 60.2200 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
0 0.000000 0.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 2 2.000000 60.2200 0.0000
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
12 11.500000 604.7700 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 12 11.500000 604.7700 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 187 433.000000 28476.7500 28476.7500
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 1 2.500000 178.6000 0.0000
T 0 0.000000 0.0000 0.0000
81 78.500000 8698.4600 0.0000
Other 70 163.500000 11189.2800 945.2200
---------------------------------------------------------
Total 339 677.500000 48543.0900 29421.9700
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 95 183.250000 12662.8700 12662.8700
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
0 0.000000 0.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 95 183.250000 12662.8700 12662.8700
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 845 679.000000 37683.3000 37683.3000
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
1118 1050.000000 64070.8000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 1963 1729.000000 101754.1000 37683.3000
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 255 492.250000 31725.5700 31725.5700
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
10 11.250000 498.1300 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 265 503.500000 32223.7000 31725.5700
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 385 742.500000 44076.8200 44064.8600
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
392 974.000000 66653.3400 0.0000
Other 11 17.000000 1245.7500 0.0000
---------------------------------------------------------
Total 795 1743.500000 112608.9100 44064.8600
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 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
613 1315.500000 89129.5300 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 613 1315.500000 89129.5300 0.0000
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 301 1081.750000 70769.5800 70769.5800
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
36 104.000000 7396.1000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 337 1185.750000 78165.6800 70769.5800
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 11 12.500000 664.3600 547.6800
D 67 90.500000 4794.7500 0.0000
S 0 0.000000 0.0000 0.0000
H 191 233.250000 15546.7400 0.0000
T 439 760.500000 48704.3700 43451.8200
346 493.000000 29360.4500 214.3200
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 1054 1589.750000 99070.6700 44213.8200
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 42 39.450000 1923.7500 1188.7500
D 10 12.000000 661.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 68 69.149800 3466.4800 3466.4800
825 878.149199 45114.4156 0.0000
Other 27 24.250000 1179.2500 0.0000
---------------------------------------------------------
Total 972 1022.998999 52344.8956 4655.2300
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 114 117.500000 6598.8500 6598.8500
713 849.990000 42027.2900 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 827 967.490000 48626.1400 6598.8500
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 440 411.220044 28187.6400 28187.6400
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
1006 802.288047 54449.5188 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 1453 1227.508091 83637.1588 28187.6400
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 30 33.273900 2271.2600 2271.2600
D 0 0.000000 0.0000 0.0000
S 5 7.726100 467.2400 467.2400
H 0 0.000000 0.0000 0.0000
T 122 367.500000 20079.5800 20079.5800
216 442.250000 28475.5300 27890.2800
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 373 850.750000 51293.6100 50708.3600