CMS/EIP Fiscal Report Statewide
Services beginning 07/01/2017 ending 09/30/2017 Date of Report:11/05/2017 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 10973 11275.25000 416992.0000 36.9829
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 7495 8619.500000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 20856 60808.75000 2248582.5000 36.9779
Subtotal (Total Children Is Unduplicated) 22125 80703.50000 2665574.5000 33.0292
-----------------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
ASTE-ASTE-ASSISTIVE TECHNOLOGY EVAL 18 24.000000 1164.0000 48.5000
AUDE-92552-PURE TONE AUDIOMETRY -AIR ONLY 40 41.000000 734.7200 17.9200
AUDE-92553-PURE TONE AUDIOMETRY AIR & BONE 2 2.000000 42.7000 21.3500
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 44 45.000000 567.4500 12.6100
AUDE-92557-COMP AUDIO THRESHOLD EVAL/SPCH RECOG 1 1.000000 21.5500 21.5500
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 50 51.000000 421.2600 8.2600
AUDE-92568-ACOUSTIC REFLEX TESTING (MEMR) 2 2.000000 18.1200 9.0600
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 47 48.000000 1214.8800 25.3100
AUDE-92582-CONDITIONED PLAY AUDIOMETRY 1 1.000000 34.9700 34.9700
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 28 28.000000 519.4000 18.5500
AUDE-92588-OTOACOUSTIC EMISSIONS (COMP) 5 5.000000 103.4000 20.6800
AUDE-V5010-ASSESSMENT FOR HEARING AID 1 1.000000 45.0000 45.0000
AUDE-V5090-DISPENSING FEE PER HEARING AID 2 3.000000 345.0000 115.0000
BEHV-BEHV-BEHAVIORAL ASSESSMENT 1 1.000000 125.0000 125.0000
EVAL-96111-DEVELOPMENTAL EVALUATION 97 121.500000 6070.7500 49.9650
EXIT-EXIT-EXIT ASSESSMENT 759 1226.500000 61250.0000 49.9389
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 112 189.000000 14175.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 63 98.000000 7350.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 24 38.500000 2887.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 67 106.500000 8156.4400 76.5863
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 161 272.500000 15001.2700 55.0505
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 1680 2588.000000 192591.3200 74.4170
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 804 1215.578800 90752.1000 74.6575
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 566 917.500000 68433.2000 74.5866
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 2198 3400.500000 187640.8200 55.1804
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 1030 1509.999970 112810.2178 74.7088
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 23 23.000000 3235.2500 140.6630
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 4 4.000000 439.2200 109.8050
NUTR-97803-NUTRITIONAL EVAL, FOLLOW-UP 32 155.000000 7750.0000 50.0000
OCTF-97168-OT RE-EVAL EST PLAN CARE 19 18.999900 959.9500 50.5240
OCTH-97165-OT EVAL LOW COMPLEXITY 8 8.000000 378.4000 47.3000
OCTH-97166-OT EVAL MODERATE COMPLEXITY 41 41.000000 2034.6600 49.6259
OCTH-97167-OT EVAL HIGH COMPLEXITY 128 128.000000 6486.4000 50.6750
PSTF-97164-PT RE-EVAL EST PLAN CARE 16 16.000000 753.9000 47.1188
PSTH-97161-PT EVAL LOW COMPLEXITY 7 7.000000 355.1600 50.7371
PSTH-97162-PT EVAL MODERATE COMPLEXITY 13 13.000000 613.6500 47.2038
PSTH-97163-PT EVAL HIGH COMPLEXITY 91 91.000000 4620.0200 50.7695
SCREEN-T1023-SCREENING 72 74.000000 3700.0000 50.0000
SENS-V5014TS-HEARING AID REPAIR IN-OFFICE 1 1.000000 50.0000 50.0000
SPCH-92521-EVAL OF SPEECH FLUENCY 1 1.000000 51.0500 51.0500
SPCH-92522-EVAL OF SPCH SOUND PROD 7 7.000000 357.3500 51.0500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 181 182.000000 9279.7200 50.9875
SPCH-92524-BEHAV & QUAL ANALYSIS OF
VOICE AND RES 26 27.000100 1378.3500 51.0498
Subtotal (Total Children Is Unduplicated) 4788 12734.07877 814919.1478 63.9951
-----------------------------------------------------------------------------------------------------------------------
EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 38 151.000000 34975.8900 231.6284
AUD-92593TS-AUDIOLOGY SERVICES (Biaural) 3 3.000000 150.0000 50.0000
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 1229 1571.000000 75925.0000 48.3291
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 72 55.750000 1393.7500 25.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 1919 3274.500000 163559.2500 49.9494
CONIP-CONIP-CONSULT, ITDS PHONE 184 149.250000 3731.2500 25.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 406 665.500000 33225.0000 49.9249
CONOP-CONOP-CONSULT, OT, PHONE 31 44.000000 1100.0000 25.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 264 319.000000 15943.7500 49.9804
CONPP-CONPP-CONSULT, PT, PHONE 8 4.250000 106.2500 25.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 1122 1255.250000 62675.0000 49.9303
CONSP-CONSP-CONSULT, SLP, PHONE 118 75.250000 1881.2500 25.0000
COUN-H2019HR-INDIVIDUAL/FAMILY THERAPY 16 36.000000 2639.5200 73.3200
DSTT-DSTT-DIRECT SERVICE COORDINATOR TRAVEL 1231 2437.750000 0.0000 0.0000
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 139 4376.000000 109400.0000 25.0000
EIIF-96154-HEALTH AND BEHAVIOR INTERVENTION 4 144.000000 7200.0000 50.0000
EIIF-EIIF_NM-EI INDIVIDUAL SESSION BY NONMED PROF 14 59.000000 2795.2000 47.3763
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 8711 58959.00000 2946255.6600 49.9713
INTR-T1013-INTERPRETER 391 1667.750000 75585.1900 45.3217
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 12835 99581.00000 998801.0000 10.0300
OCCT-97530-OT SESSION BY LICENSED OT 1047 5067.750198 354761.1998 70.0037
OCCT-97530HM-OT SESSION BY OT ASST 291 1730.250000 98809.4000 57.1070
PHY-97110-PT SESSION BY LICENSED PT 1006 4869.750200 332793.5800 68.3389
PHY-97110HM-PT SESSION BY PT ASST 184 901.250610 51544.0474 57.1917
SENS-V5050-IN EAR MONAURAL HEARING AID 3 3.000000 684.0000 228.0000
SENS-V5140-BEHIND EAR BINAURAL HEARING AID
2 3.000000 1368.0000 456.0000
SENS-V5264-EARMOLD 8 15.000000 270.0000 18.0000
CMS/EIP Fiscal Report Statewide
Services beginning 07/01/2017 ending 09/30/2017 Date of Report:11/05/2017 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
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 2361 17278.44190 997135.6800 57.7098
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 17 81.000000 4578.2000 56.5210
SPL-92508-GROUP SPL SESSION PER CHILD 27 103.000000 1374.1200 13.3410
TRAV-TRAVS-Travel by mile 5549 522810.0000 230785.0000 0.4414
Subtotal (Total Children Is Unduplicated) 15560 727690.6929 6611446.1872 9.0855
-----------------------------------------------------------------------------------------------------------------------
Total 821128.271675 10091939.8350 12.2903
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 24065
-----------------------------------------------------------------------------------------------------------------------
Center 01
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 5 3.500000 168.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 6718 4475.500000 177575.7600 0.0000
P 16520 68879.750000 314492.5600 314492.5600
D 999 3508.500000 30520.6000 0.0000
S 1050 789.750000 29749.1900 0.0000
H 150 173.000000 12021.6900 0.0000
T 2142 9770.750000 35525.8200 35507.3100
6072 4015.750000 119990.2700 0.0000
Other 122 127.500000 7601.8200 0.0000
---------------------------------------------------------
Total 33778 91744.000000 727646.2100 349999.8700
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 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 4720 12022.250000 120975.1900 120465.9200
129 267.000000 3192.6000 0.0000
Other 4787 15006.500000 102881.9300 0.0000
---------------------------------------------------------
Total 9636 27295.750000 227049.7200 120465.9200
Center 03
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 53 45.750000 1705.7500 0.0000
U 0 0.000000 0.0000 0.0000
B 2586 1508.000000 57187.5000 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
17173 86650.000000 344363.1200 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 19812 88203.750000 403256.3700 0.0000
Center 04
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 12 11.250000 416.2500 0.0000
U 0 0.000000 0.0000 0.0000
B 275 347.250000 13094.2500 0.0000
P 6587 17875.750000 416548.0700 416316.8200
D 45 65.750000 2432.7500 0.0000
S 1 0.250000 9.2500 0.0000
H 2402 9450.000000 477546.1200 1417.2800
T 0 0.000000 0.0000 0.0000
3739 7327.250000 254430.9000 0.0000
Other 71 133.500000 8528.7000 648.4100
---------------------------------------------------------
Total 13132 35211.000000 1173006.2900 418382.5100
Center 05
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 2954 1803.500000 70895.7500 0.0000
P 4395 51266.000000 144291.2600 144506.7380
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 1 0.500000 18.5000 0.0000
2767 1523.750000 43226.1100 82.8900
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 10117 54593.750000 258431.6200 144589.6280
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 7784 7430.000000 163580.4500 163580.4500
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
16870 12600.000000 397498.1700 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 24654 20030.000000 561078.6200 163580.4500
Center 07
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 7 6.500000 240.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 18 14.750000 621.7500 0.0000
P 8017 11248.000000 305130.3600 305130.3600
D 154 96.000000 3776.0000 0.0000
S 3 4.000000 281.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 1 0.500000 18.5000 0.0000
6115 3813.750000 111570.3300 0.0000
Other 1 1.250000 46.2500 0.0000
---------------------------------------------------------
Total 14316 15184.750000 421684.6900 305130.3600
Center 09
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 9 6.000000 222.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 193 163.750000 6548.0700 375.0000
P 18627 147777.000000 790494.6900 790575.1700
D 16 21.000000 1441.9800 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
2688 11311.750000 417876.4200 0.0000
Other 154 247.750000 18348.0000 0.0000
---------------------------------------------------------
Total 21687 159527.250000 1234931.1600 790950.1700
Center 10
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 6 6.000000 222.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 9061 6778.500000 282622.0000 0.0000
P 8015 23909.250000 609588.6800 609588.6800
D 120 60.000000 2220.0000 0.0000
S 44 70.250000 4993.2500 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
8613 14100.000000 658204.2300 0.0000
Other 4 1.250000 46.2500 0.0000
---------------------------------------------------------
Total 25863 44925.250000 1557896.4100 609588.6800
Center 51
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 45 22.250000 823.2500 0.0000
U 0 0.000000 0.0000 0.0000
B 1763 1047.750000 40710.5000 0.0000
P 1966 9365.500000 180385.8500 180385.8500
D 22 11.750000 460.7500 0.0000
S 0 0.000000 0.0000 0.0000
H 1 1.000000 50.0000 0.0000
T 0 0.000000 0.0000 0.0000
3375 4379.750000 216481.0100 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 7172 14828.000000 438911.3600 180385.8500
Center 52
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 752 727.750000 39102.7500 9.2500
P 2064 1747.500000 76675.5200 75984.5600
D 81 85.250000 4731.7600 130.0000
S 3 16.000000 106.2300 6.2300
H 228 252.250000 16552.1300 0.0000
T 6849 57611.500000 245305.7800 233792.6300
3840 4169.750000 158889.9200 2295.5700
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 13817 64610.000000 541364.0900 312218.2400
Center 53
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 9 7.500000 342.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 348 244.500000 9046.5000 0.0000
P 2631 2497.156640 113461.1602 113250.1600
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 1850 14681.000000 20709.2100 20709.2100
T 1505 10300.240223 17359.0767 17336.5800
15025 26284.103107 294957.7009 0.0000
Other 35 37.000000 1848.6400 0.0000
---------------------------------------------------------
Total 21403 54051.499970 457724.7878 151295.9500
Center 54
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 1 0.250000 9.2500 0.0000
U 0 0.000000 0.0000 0.0000
B 4877 3892.500000 168941.0800 0.0000
P 1 1.000000 50.0000 0.0000
D 0 0.000000 0.0000 0.0000
S 2 1.250000 46.2500 0.0000
H 9598 62366.276800 122926.6606 122926.6600
T 897 6451.000000 13271.5900 13234.5900
13097 13435.973198 293491.8492 0.0000
Other 2 3.000000 168.0000 0.0000
---------------------------------------------------------
Total 28475 86151.249998 598904.6798 136161.2500
Center 55
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 2 1.250000 46.2500 0.0000
P 13801 19505.564936 369447.6600 369447.6600
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 5 10.000000 750.0000 0.0000
T 0 0.000000 0.0000 0.0000
9054 6968.456771 361706.6374 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 22862 26485.271707 731950.5474 369447.6600
Center 57
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 55 40.250000 1526.7500 0.0000
U 0 0.000000 0.0000 0.0000
B 1834 1748.750000 69778.2500 0.0000
P 1037 993.000000 41909.0300 41872.0300
D 10 7.750000 286.7500 0.0000
S 137 161.500000 5880.9900 5880.9900
H 0 0.000000 0.0000 0.0000
T 3605 27313.750000 254667.4000 254579.7800
4374 7988.250000 382979.0900 285689.6400
Other 25 33.500000 1075.0200 1075.0200
---------------------------------------------------------
Total 11077 38286.750000 758103.2800 589097.4600