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: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 12234 13546.50000 501075.5000 36.9893
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 9691 14818.25000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 7731 24231.50000 895436.7500 36.9534
Subtotal (Total Children Is Unduplicated) 19092 52596.25000 1396512.2500 26.5516
-----------------------------------------------------------------------------------------------------------------------
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 87 106.842600 5342.1300 50.0000
EXIT-EXIT-EXIT ASSESSMENT 794 1335.500000 65040.5700 48.7013
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 40 51.500000 3851.1200 74.7790
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 10 13.500000 1012.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 26 52.000000 3900.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 54 71.000000 3900.5000 54.9366
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 463 627.120762 46604.4875 74.3150
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 154 225.260033 16854.5025 74.8224
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 172 242.701000 18165.0750 74.8455
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 755 960.500000 53126.5200 55.3113
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 348 529.251822 39502.0867 74.6376
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 31 31.000000 1660.0500 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 10 10.000000 500.0000 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) 2478 5071.287383 287152.2117 56.6231
-----------------------------------------------------------------------------------------------------------------------
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 1467 1733.000000 86375.0000 49.8413
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 87 68.000000 1700.0000 25.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 2139 3752.000000 187431.0000 49.9550
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 1197 1446.750000 72337.5000 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 2976 21437.50000 1060518.9600 49.4703
INTR-T1013-INTERPRETER 479 1818.500000 84893.6300 46.6833
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 13402 201445.5000 1176277.9800 5.8392
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:Program Patients
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
TRAV-TRAVS-Travel by mile 5785 553238.0000 244145.0500 0.4413
Subtotal (Total Children Is Unduplicated) 15786 801846.2317 4036966.3617 5.0346
-----------------------------------------------------------------------------------------------------------------------
Total 859513.769125 5720630.8234 6.6557
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 23555
-----------------------------------------------------------------------------------------------------------------------
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 18923 83064.250000 309636.0600 309636.0600
D 680 3666.750000 14390.4200 0.0000
S 18 11.000000 379.2500 0.0000
H 0 0.000000 0.0000 0.0000
T 2086 7727.000000 39591.2300 39563.4800
6993 4810.250000 144287.9700 0.0000
Other 1 1.000000 55.5000 0.0000
---------------------------------------------------------
Total 28701 99280.250000 508340.4300 349199.5400
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 5212 12274.500000 130456.7100 130804.2400
151 136.750000 6813.7700 0.0000
Other 3616 15502.000000 59658.5000 99.0000
---------------------------------------------------------
Total 8980 27913.750000 196947.4800 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 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
15984 74671.250000 327364.8400 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 15984 74671.250000 327364.8400 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
3675 3264.000000 132850.9100 0.0000
Other 12 23.000000 1394.4800 180.0000
---------------------------------------------------------
Total 7676 19387.750000 415842.6800 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 5553 64705.000000 167946.2800 167546.8300
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
2948 1723.750000 48714.7300 346.4800
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 8501 66428.750000 216661.0100 167893.3100
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 7487 7296.000000 142961.8700 142961.8700
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
12636 8847.750000 210221.0400 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 20123 16143.750000 353182.9100 142961.8700
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 4451 11158.750000 229315.7300 229315.7300
D 170 98.250000 3803.7500 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
7738 4998.750000 142941.8900 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 12360 16256.250000 376079.8700 229315.7300
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 15834 148021.250000 647066.6200 647066.6200
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
47 222.500000 4172.2700 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 15881 148243.750000 651238.8900 647066.6200
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
6419 4909.750000 148184.7500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 16708 35087.000000 906268.6100 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 1693 89632.750000 113346.3700 113356.3700
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
3731 2674.500000 93743.6000 10.0000
Other 1 1.000000 10.0000 10.0000
---------------------------------------------------------
Total 5425 92308.250000 207099.9700 113376.3700
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 7026 62014.500000 224505.6900 217961.8100
3156 2169.750000 45741.4100 190.8600
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 10204 64201.750000 271026.3500 218252.6700
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 5989 46738.001822 65750.1467 65750.1500
12595 9576.000000 154788.9400 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 18586 56315.251822 220598.3367 65750.1500
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 12877 82572.350000 160750.5400 160750.5400
13065 9994.750000 145073.0000 0.0000
Other 1 0.500000 18.5000 0.0000
---------------------------------------------------------
Total 25943 92567.600000 305842.0400 160750.5400
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 11315 18189.785737 270908.2667 270908.2800
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
4401 2819.881566 96659.9400 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 15716 21009.667303 367568.2067 270908.2800
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 4035 26666.250000 278935.3400 278833.8800
2913 2642.250000 106918.0000 4540.0000
Other 2 2.000000 81.4400 81.4400
---------------------------------------------------------
Total 7100 29587.000000 392915.4500 289661.9900