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: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 12235 13546.75000 501084.7500 36.9893
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 9734 14975.25000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 23424 74635.75000 2759279.0000 36.9699
Subtotal (Total Children Is Unduplicated) 24537 103157.7500 3260363.7500 31.6056
-----------------------------------------------------------------------------------------------------------------------
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 90 117.250000 5862.5000 50.0000
EXIT-EXIT-EXIT ASSESSMENT 795 1336.500000 65090.5700 48.7023
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 182 314.500000 23196.1200 73.7555
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 87 173.500000 12842.5000 74.0202
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 43 64.500000 4837.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 140 239.000000 17931.2700 75.0262
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 230 391.500000 21688.2500 55.3978
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 2393 3648.500003 272383.7306 74.6564
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 1066 1603.500030 119628.6225 74.6047
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 820 1241.000100 92821.3475 74.7956
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 3129 4882.000000 269978.3300 55.3008
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 1673 2567.000821 193955.3623 75.5572
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 76 76.000000 7905.7700 104.0233
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 103 104.000000 5200.0000 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) 6362 17953.75095 1158639.8729 64.5347
-----------------------------------------------------------------------------------------------------------------------
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 1479 1755.750000 87512.5000 49.8434
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 88 69.000000 1725.0000 25.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 2144 3762.500000 187956.0000 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 1199 1452.750000 72637.5000 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 9186 70575.00000 3516911.5600 49.8323
INTR-T1013-INTERPRETER 479 1818.500000 84893.6300 46.6833
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 13409 201595.5000 1177777.9800 5.8423
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:Program Patients
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 5824 561665.0000 247870.1500 0.4413
Subtotal (Total Children Is Unduplicated) 16260 880292.1307 7716274.0174 8.7656
-----------------------------------------------------------------------------------------------------------------------
Total 1001403.631645 12135277.6403 12.1183
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 26213
-----------------------------------------------------------------------------------------------------------------------
Center 01
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 89 79.750000 3570.6700 0.0000
U 0 0.000000 0.0000 0.0000
B 8539 5851.750000 232075.5500 0.0000
P 20071 84252.000000 380119.1300 380119.1300
D 836 3829.250000 23240.6400 0.0000
S 565 447.500000 16529.7500 0.0000
H 88 113.500000 7986.6000 0.0000
T 2407 8050.500000 58193.3800 57971.3800
7059 4870.250000 147664.6400 0.0000
Other 90 137.000000 9145.5000 0.0000
---------------------------------------------------------
Total 39744 107631.500000 878525.8600 438090.5100
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 5212 12274.500000 130456.7100 130804.2400
151 136.750000 6813.7700 0.0000
Other 5563 16964.750000 123680.5000 99.0000
---------------------------------------------------------
Total 10929 29378.500000 261029.7000 130903.2400
Center 03
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 1606 998.500000 38228.2500 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
17316 75506.250000 358616.5500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 18922 76504.750000 396844.8000 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 3212 4946.750000 186561.0000 0.0000
P 5442 18200.250000 384447.7600 384465.3300
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
4500 8286.000000 297115.7200 0.0000
Other 82 186.500000 12583.7600 1125.2200
---------------------------------------------------------
Total 15986 42727.750000 1442795.9600 386324.2100
Center 05
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 10 6.000000 222.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 2816 1909.500000 76661.0000 0.0000
P 5650 64890.750000 180746.6500 180347.2000
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
2949 1724.000000 48723.9800 346.4800
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 11425 68530.250000 306353.6300 180693.6800
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 8332 7975.000000 180645.1700 180645.1700
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
19600 14331.000000 464265.8700 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 27932 22306.000000 644911.0400 180645.1700
Center 07
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 24 20.250000 749.2500 0.0000
P 10542 16268.250000 452195.3000 452186.0500
D 170 98.250000 3803.7500 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
7845 5113.500000 148612.5200 0.0000
Other 3 3.000000 111.0000 0.0000
---------------------------------------------------------
Total 18589 21505.500000 605555.0700 452186.0500
Center 09
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 2 3.000000 225.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 61 69.750000 3655.5000 0.0000
P 21517 158238.500000 905805.0900 908365.1990
D 11 15.000000 949.5000 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
2894 11200.750000 466379.0900 0.0000
Other 231 335.000000 24764.2500 0.0000
---------------------------------------------------------
Total 24716 169862.000000 1401778.4300 908365.1990
Center 10
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 10 4.500000 166.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 10518 8246.000000 347868.0000 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
10392 17874.500000 835525.4500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 31213 56306.000000 1941877.5600 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 2478 1558.500000 61166.5000 0.0000
P 1994 90714.500000 184115.9500 184125.9500
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
4629 5392.250000 255070.3600 10.0000
Other 1 1.000000 10.0000 10.0000
---------------------------------------------------------
Total 9134 97681.250000 500936.3100 184145.9500
Center 52
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 392 423.500000 21400.7500 142.5000
P 3140 2831.000000 129913.8400 129566.6800
D 97 117.250000 6199.2800 0.0000
S 5 7.000000 450.0000 0.0000
H 351 386.500000 26119.1400 0.0000
T 7479 62896.000000 274810.8900 262860.4600
4413 5514.000000 183553.1900 10421.7800
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 15877 72175.250000 642447.0900 402991.4200
Center 53
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 3 1.500000 55.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 460 384.500000 16606.5000 1470.7500
P 4180 4052.950000 183187.2500 182337.5000
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 6059 46809.651622 69404.1267 69404.1300
15643 12725.649199 316738.0556 0.0000
Other 33 29.750000 1506.0000 0.0000
---------------------------------------------------------
Total 26391 64018.500821 588276.9323 253230.8800
Center 54
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 3196 2672.250000 116383.7500 0.0000
P 30 29.000000 1505.5000 1487.0000
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 13011 82707.850000 168164.3900 168145.8900
21060 17728.740000 517503.8300 0.0000
Other 4 1.250000 46.2500 0.0000
---------------------------------------------------------
Total 37303 103141.340000 803686.9700 169632.8900
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 15827 22291.755781 450891.1567 450780.3500
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 8 16.000000 1150.0000 0.0000
T 0 0.000000 0.0000 0.0000
9568 7619.035043 398241.5813 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 25407 29932.790824 850656.7380 450780.3500
Center 57
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 2 3.000000 111.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 1329 1305.500000 50366.2500 0.0000
P 2157 2116.023900 90316.7600 90316.7600
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 4161 27041.750000 299536.9200 299435.4600
4724 8722.750000 414748.4700 310082.2200
Other 38 69.500000 1653.7400 1653.7400
---------------------------------------------------------
Total 12566 39542.750000 864181.0500 708162.0900