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
Agency Filter:EXT
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 3 1.500000 55.5000 37.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 13 19.750000 730.7500 37.0000
Subtotal (Total Children Is Unduplicated) 16 21.250000 786.2500 37.0000
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Screening, Eval, and Assessment,Class #02
ASTE-ASTE-ASSISTIVE TECHNOLOGY EVAL 10 11.000000 533.5000 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 7 15.250000 758.2500 49.7213
EXIT-EXIT-EXIT ASSESSMENT 280 496.500000 24750.0000 49.8489
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 7 11.017200 826.2900 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 6 11.500000 862.5000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 3 5.500000 412.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 2 1.990223 149.2667 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 6 7.500000 416.2500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 90 131.264799 9590.6600 73.0635
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 28 38.675866 2900.6900 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 50 77.500000 5812.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 105 175.000000 9502.8700 54.3021
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 68 105.000000 7875.0000 75.0000
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 5 5.000000 253.0600 50.6120
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
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 75 75.000000 3817.3700 50.8983
SPCH-92524-BEHAV & QUAL ANALYSIS OF
VOICE AND RES 14 14.020600 715.7500 51.0499
Subtotal (Total Children Is Unduplicated) 868 1541.426580 80698.0967 52.3529
-----------------------------------------------------------------------------------------------------------------------
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 987 1215.000000 58125.0000 47.8395
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 58 44.000000 1100.0000 25.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 1653 2310.250000 115437.5000 49.9675
CONIP-CONIP-CONSULT, ITDS PHONE 169 141.000000 3525.0000 25.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 363 614.500000 30675.0000 49.9186
CONOP-CONOP-CONSULT, OT, PHONE 29 42.750000 1068.7500 25.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 199 255.250000 12756.2500 49.9755
CONPP-CONPP-CONSULT, PT, PHONE 8 4.250000 106.2500 25.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 909 1014.250000 50625.0000 49.9137
CONSP-CONSP-CONSULT, SLP, PHONE 113 71.250000 1781.2500 25.0000
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 33 152.000000 3800.0000 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 2344 14161.10000 707162.9800 49.9370
INTR-T1013-INTERPRETER 164 1200.250000 52210.1900 43.4994
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 12154 92007.00000 923070.0000 10.0326
OCCT-97530-OT SESSION BY LICENSED OT 470 2096.689799 145791.3500 69.5341
OCCT-97530HM-OT SESSION BY OT ASST 81 424.449650 24278.4200 57.1998
PHY-97110-PT SESSION BY LICENSED PT 463 2025.837187 139679.3064 68.9489
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 1022 5464.010053 382230.2700 69.9542
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 4923 432600.0000 190779.1400 0.4410
Subtotal (Total Children Is Unduplicated) 13831 556342.0386 2890032.1464 5.1947
-----------------------------------------------------------------------------------------------------------------------
Total 557904.715159 2971516.4931 5.3262
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Number of Children (Unduplicated) With at Least One Service 13956
-----------------------------------------------------------------------------------------------------------------------
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 690 3197.000000 13057.5000 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 1951 9561.250000 24587.4300 24587.4300
17 96.000000 268.2200 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 17613 80137.000000 261934.3600 248608.6400
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 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 4669 12119.750000 113229.5100 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
12093 83776.250000 261313.6300 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 12093 83776.250000 261313.6300 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 3407 12977.750000 224007.6700 224007.6700
D 2 2.000000 74.0000 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
20 19.250000 712.2500 0.0000
Other 7 16.000000 848.4100 297.2800
---------------------------------------------------------
Total 3456 13083.000000 226602.3300 225264.9500
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 4143 50447.750000 124889.7700 124530.0880
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
4 8.000000 84.1100 82.8900
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 4147 50455.750000 124973.8800 124612.9780
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
4415 4315.500000 67603.2100 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 10734 10519.500000 163343.5400 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 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 3178 7551.250000 149922.0500 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 3536 85148.250000 220365.9400 220365.9400
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
32 810.000000 2673.3100 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 3568 85958.250000 223039.2500 220365.9400
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 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 7951 23812.750000 604368.2900 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 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
32 35.000000 2382.6000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 1682 5265.500000 108466.2800 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 0 0.000000 0.0000 0.0000
S 1 14.000000 6.2300 6.2300
H 0 0.000000 0.0000 0.0000
T 3355 30199.000000 124765.3200 124765.3200
7 184.750000 270.9400 118.0600
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 3363 30397.750000 125042.4900 124889.6100
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
2229 15847.750000 26047.1300 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 5560 40804.990223 62915.4167 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 881 6435.500000 12402.3900 12402.3900
578 3064.750000 6162.9000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 10963 71770.660000 136118.6064 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
0 0.000000 0.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 9443 15672.564936 196967.6900 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 0 0.000000 0.0000 0.0000
S 117 151.000000 5152.3100 5152.3100
H 0 0.000000 0.0000 0.0000
T 3345 26428.750000 208126.8600 208169.7400
0 0.000000 0.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 3462 26579.750000 213279.1700 213322.0500