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
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 10973 11275.25000 416992.0000 36.9829
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 7494 8618.750000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 6973 20173.50000 745923.0000 36.9754
Subtotal (Total Children Is Unduplicated) 16874 40067.50000 1162915.0000 29.0239
-----------------------------------------------------------------------------------------------------------------------
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 36 37.000000 663.0400 17.9200
AUDE-92553-PURE TONE AUDIOMETRY AIR & BONE 1 1.000000 21.3500 21.3500
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 38 39.000000 491.7900 12.6100
AUDE-92557-COMP AUDIO THRESHOLD EVAL/SPCH RECOG 1 1.000000 21.5500 21.5500
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 44 45.000000 371.7000 8.2600
AUDE-92568-ACOUSTIC REFLEX TESTING (MEMR) 2 2.000000 18.1200 9.0600
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 41 42.000000 1063.0200 25.3100
AUDE-92582-CONDITIONED PLAY AUDIOMETRY 1 1.000000 34.9700 34.9700
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 25 25.000000 463.7500 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 1 2.000000 230.0000 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 758 1224.500000 61150.0000 49.9388
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 21 24.017200 1801.2900 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 12 15.500000 1162.5000 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 8 9.990223 749.2667 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 29 35.500000 1970.2500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 336 445.130797 33130.6100 74.4289
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 116 145.675866 10925.6900 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 110 161.500000 12112.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 597 751.500000 41498.6200 55.2211
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 210 297.000000 22237.5000 74.8737
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 8 8.000000 428.4000 53.5500
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 1 1.000000 26.6100 26.6100
NUTR-97803-NUTRITIONAL EVAL, FOLLOW-UP 15 30.000000 1500.0000 50.0000
OCTF-97168-OT RE-EVAL EST PLAN CARE 13 11.687324 586.6400 50.1946
OCTH-97165-OT EVAL LOW COMPLEXITY 1 1.000000 51.0500 51.0500
OCTH-97166-OT EVAL MODERATE COMPLEXITY 18 18.000000 875.8400 48.6578
OCTH-97167-OT EVAL HIGH COMPLEXITY 52 52.000000 2606.6000 50.1269
PSTF-97164-PT RE-EVAL EST PLAN CARE 9 9.000000 436.5500 48.5056
PSTH-97161-PT EVAL LOW COMPLEXITY 6 6.000000 304.1100 50.6850
PSTH-97162-PT EVAL MODERATE COMPLEXITY 5 5.000000 255.2500 51.0500
PSTH-97163-PT EVAL HIGH COMPLEXITY 28 27.020568 1353.8700 50.1052
SCREEN-T1023-SCREENING 9 9.000000 450.0000 50.0000
SENS-V5014TS-HEARING AID REPAIR IN-OFFICE 1 1.000000 50.0000 50.0000
SPCH-92522-EVAL OF SPCH SOUND PROD 3 3.000000 153.1500 51.0500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 88 88.000000 4481.0200 50.9207
SPCH-92524-BEHAV & QUAL ANALYSIS OF
VOICE AND RES 14 14.020600 715.7500 51.0499
Subtotal (Total Children Is Unduplicated) 2015 3752.542578 212725.5067 56.6884
-----------------------------------------------------------------------------------------------------------------------
EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 33 113.000000 24870.2900 220.0911
AUD-92593TS-AUDIOLOGY SERVICES (Biaural) 1 1.000000 50.0000 50.0000
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 1200 1528.500000 73800.0000 48.2826
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 67 50.500000 1262.5000 25.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 1905 3259.500000 162809.2500 49.9491
CONIP-CONIP-CONSULT, ITDS PHONE 184 148.750000 3718.7500 25.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 406 661.000000 33000.0000 49.9244
CONOP-CONOP-CONSULT, OT, PHONE 31 44.000000 1100.0000 25.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 263 318.000000 15893.7500 49.9803
CONPP-CONPP-CONSULT, PT, PHONE 8 4.250000 106.2500 25.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 1112 1245.000000 62162.5000 49.9297
CONSP-CONSP-CONSULT, SLP, PHONE 118 75.250000 1881.2500 25.0000
COUN-H2019HR-INDIVIDUAL/FAMILY THERAPY 2 5.000000 366.6000 73.3200
DSTT-DSTT-DIRECT SERVICE COORDINATOR TRAVEL 1089 2237.750000 0.0000 0.0000
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 33 154.000000 3850.0000 25.0000
EIIF-96154-HEALTH AND BEHAVIOR INTERVENTION 1 8.000000 400.0000 50.0000
EIIF-EIIF_NM-EI INDIVIDUAL SESSION BY NONMED PROF 13 38.000000 1900.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 2480 14704.60000 734337.9800 49.9393
INTR-T1013-INTERPRETER 390 1663.250000 75360.1900 45.3090
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 12832 99529.00000 998281.0000 10.0301
OCCT-97530-OT SESSION BY LICENSED OT 476 2104.939799 146380.7300 69.5415
OCCT-97530HM-OT SESSION BY OT ASST 83 426.449650 24392.8200 57.1998
PHY-97110-PT SESSION BY LICENSED PT 469 2041.587187 140804.4864 68.9681
PHY-97110HM-PT SESSION BY PT ASST 46 252.701890 14444.4400 57.1600
SENS-V5050-IN EAR MONAURAL HEARING AID 2 2.000000 456.0000 228.0000
SENS-V5140-BEHIND EAR BINAURAL HEARING AID
2 3.000000 1368.0000 456.0000
SENS-V5264-EARMOLD 6 11.000000 198.0000 18.0000
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 1065 5601.010053 392017.5500 69.9905
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
Payclass Filters:GR
Eligibility Filter:Part C (excluding not eligible)
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 7 28.500000 1630.2000 57.2000
SPL-92508-GROUP SPL SESSION PER CHILD 8 41.000000 513.5600 12.5259
TRAV-TRAVS-Travel by mile 5324 469854.0000 207360.8600 0.4413
Subtotal (Total Children Is Unduplicated) 14911 606154.5386 3124716.9564 5.1550
-----------------------------------------------------------------------------------------------------------------------
Total 649974.581157 4500357.4631 6.9239
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 21636
-----------------------------------------------------------------------------------------------------------------------
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 14955 67282.750000 224021.2100 224021.2100
D 692 3197.500000 13076.0000 0.0000
S 3 2.500000 92.5000 0.0000
H 0 0.000000 0.0000 0.0000
T 1952 9573.250000 24592.7300 24592.7300
6016 3960.000000 116884.5200 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 23618 84016.000000 378666.9600 248613.9400
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 4557 11862.250000 110683.4300 110174.1600
112 257.500000 2546.0800 0.0000
Other 3156 13801.500000 49536.1800 0.0000
---------------------------------------------------------
Total 7825 25921.250000 162765.6900 110174.1600
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
16881 86441.750000 336488.6300 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 16881 86441.750000 336488.6300 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 3408 12978.750000 224057.6700 224057.6700
D 45 65.750000 2432.7500 0.0000
S 0 0.000000 0.0000 0.0000
H 20 68.000000 960.0000 960.0000
T 0 0.000000 0.0000 0.0000
2971 2745.000000 110394.1100 0.0000
Other 7 16.000000 848.4100 297.2800
---------------------------------------------------------
Total 6451 15873.500000 338692.9400 225314.9500
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 4285 51091.250000 132765.0200 132405.3380
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
2766 1523.500000 43216.8600 82.8900
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 7051 52614.750000 175981.8800 132488.2280
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 6319 6204.000000 95740.3300 95740.3300
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
11161 8059.750000 184125.2100 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 17480 14263.750000 279865.5400 95740.3300
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 3178 7551.250000 149922.0500 149922.0500
D 154 96.000000 3776.0000 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
6024 3737.250000 108374.7500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 9356 11384.500000 262072.8000 149922.0500
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 11682 91617.250000 442743.7100 442743.7100
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
103 867.750000 4734.3100 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 11785 92485.000000 447478.0200 442743.7100
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 7951 23812.750000 604368.2900 604368.2900
D 120 60.000000 2220.0000 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
5608 4069.250000 127664.2500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 13679 27942.000000 734252.5400 604368.2900
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 1650 5230.500000 106083.6800 106083.6800
D 4 2.750000 127.7500 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
2515 1749.250000 63284.6400 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 4169 6982.500000 169496.0700 106083.6800
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 0 0.000000 0.0000 0.0000
D 4 3.000000 214.3200 90.0000
S 1 14.000000 6.2300 6.2300
H 0 0.000000 0.0000 0.0000
T 6079 56346.000000 168177.4900 165510.5000
2829 1851.250000 37810.3800 186.7500
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 8913 58214.250000 206208.4200 165793.4800
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 0 0.000000 0.0000 0.0000
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 1837 14668.000000 20059.2100 20059.2100
T 1494 10289.240223 16809.0767 16786.5800
12064 23326.750000 143189.2300 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 15395 48283.990223 180057.5167 36845.7900
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 9504 62270.410000 117553.3164 117553.3200
T 882 6436.500000 12439.3900 12402.3900
9449 9656.250000 105891.1900 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 19835 78363.160000 235883.8964 129955.7100
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 9443 15672.564936 196967.6900 196967.6900
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
4371 2596.115998 87225.7000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 13814 18268.680934 284193.3900 196967.6900
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 10 7.750000 286.7500 0.0000
S 117 151.000000 5152.3100 5152.3100
H 0 0.000000 0.0000 0.0000
T 3347 26430.750000 208257.3600 208169.7400
2642 2330.000000 94556.7500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 6116 28919.500000 308253.1700 213322.0500