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: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 11796 12076.25000 446619.7500 36.9833
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 8250 9488.000000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 22359 66554.75000 2461094.0000 36.9785
Subtotal (Total Children Is Unduplicated) 23665 88119.00000 2907713.7500 32.9976
-----------------------------------------------------------------------------------------------------------------------
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 101 127.250000 6358.2500 49.9666
EXIT-EXIT-EXIT ASSESSMENT 760 1227.500000 61300.0000 49.9389
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 135 225.500000 16912.5000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 70 109.500000 8089.0200 73.8723
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 34 54.000000 4050.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 79 123.500000 9377.4400 75.9307
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 182 302.500000 16666.2700 55.0951
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 2165 3316.000000 246806.8400 74.4291
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 997 1489.578800 111162.1000 74.6265
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 733 1168.000000 87030.2000 74.5122
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 2831 4339.500000 239582.9700 55.2098
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 1322 1939.999970 144805.2578 74.6419
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 29 29.000000 4057.4500 139.9121
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 20 19.999900 1011.0000 50.5503
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 76 78.000000 3900.0000 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) 5759 15483.82877 1001014.6278 64.6490
-----------------------------------------------------------------------------------------------------------------------
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 1231 1571.750000 75962.5000 48.3299
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 72 55.750000 1393.7500 25.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 1922 3284.000000 164034.2500 49.9495
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 1364 2566.500000 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 8716 58991.00000 2947855.6600 49.9713
INTR-T1013-INTERPRETER 426 1736.500000 78983.1900 45.4841
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 13084 100058.0000 1003601.0000 10.0302
OCCT-97530-OT SESSION BY LICENSED OT 1048 5068.500198 354814.7798 70.0039
OCCT-97530HM-OT SESSION BY OT ASST 292 1733.750000 99009.6000 57.1072
PHY-97110-PT SESSION BY LICENSED PT 1007 4873.750200 333079.3400 68.3415
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:Program Patients
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 5781 530498.0000 234195.8500 0.4415
Subtotal (Total Children Is Unduplicated) 15972 736103.6929 6625707.0772 9.0011
-----------------------------------------------------------------------------------------------------------------------
Total 839706.521675 10534435.4550 12.5454
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 25626
-----------------------------------------------------------------------------------------------------------------------
Center 01
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 5 3.500000 168.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 7082 4764.750000 189434.0100 0.0000
P 16585 69631.000000 316945.2900 316945.2900
D 1004 3555.500000 30650.3500 0.0000
S 1111 860.000000 31876.6900 6.2500
H 162 188.000000 13146.6900 0.0000
T 2148 9798.750000 35991.2000 35972.6900
6409 4270.500000 128110.2700 0.0000
Other 124 131.500000 7862.8200 0.0000
---------------------------------------------------------
Total 34630 93203.500000 754185.8200 352924.2300
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 4769 12757.500000 122286.0600 121626.7900
129 267.000000 3192.6000 0.0000
Other 5265 16660.500000 113916.3100 0.0000
---------------------------------------------------------
Total 10163 29685.000000 239394.9700 121626.7900
Center 03
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 61 56.750000 2112.7500 0.0000
U 0 0.000000 0.0000 0.0000
B 2813 1683.500000 63681.0000 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
17656 87009.250000 355614.6200 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 20530 88749.500000 421408.3700 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 293 381.500000 14380.5000 0.0000
P 6832 18330.750000 435057.0700 434825.8200
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
4156 7722.750000 273069.6000 0.0000
Other 71 133.500000 8528.7000 648.4100
---------------------------------------------------------
Total 13812 36095.750000 1211440.2400 436891.5100
Center 05
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 3105 1937.250000 76509.5000 0.0000
P 4489 51936.500000 148412.6000 148628.0780
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
3058 1734.000000 49266.3600 82.8900
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 10653 55608.250000 274206.9600 148710.9680
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 7787 7436.000000 163944.4500 163944.4500
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
17612 13224.250000 424108.6700 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 25399 20660.250000 588053.1200 163944.4500
Center 07
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 7 6.500000 240.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 22 18.250000 751.2500 0.0000
P 8405 11727.750000 325894.6800 325894.6800
D 163 107.500000 4362.2500 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
6609 4227.000000 124526.3300 0.0000
Other 2 1.500000 55.5000 0.0000
---------------------------------------------------------
Total 15212 16093.000000 456130.0100 325894.6800
Center 09
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 10 7.500000 334.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 201 175.500000 7200.5700 683.2500
P 19290 148912.250000 829928.9200 830009.4000
D 21 27.500000 1861.2300 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
2733 11377.750000 422350.6700 0.0000
Other 215 341.250000 25360.5000 0.0000
---------------------------------------------------------
Total 22470 160841.750000 1287036.3900 830692.6500
Center 10
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 13 10.000000 370.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 9425 7171.750000 300508.5000 0.0000
P 8017 23913.250000 609708.6800 609708.6800
D 124 64.250000 2377.2500 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
8918 14491.500000 676536.7300 0.0000
Other 4 1.250000 46.2500 0.0000
---------------------------------------------------------
Total 26545 45722.250000 1594540.6600 609708.6800
Center 51
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 45 22.250000 823.2500 0.0000
U 0 0.000000 0.0000 0.0000
B 1872 1136.750000 44295.0000 0.0000
P 2002 9401.500000 181841.8500 181841.8500
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
3637 4589.500000 224059.2600 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 7579 15162.750000 451530.1100 181841.8500
Center 52
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 814 803.500000 43598.2500 9.2500
P 2217 1913.500000 83992.2700 83301.3100
D 90 100.750000 5592.0100 130.0000
S 3 16.000000 106.2300 6.2300
H 247 286.750000 18964.1300 0.0000
T 6955 58947.500000 249479.3800 237565.9800
4128 4391.500000 166829.3800 2295.5700
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 14454 66459.500000 568561.6500 323308.3400
Center 53
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 9 7.500000 342.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 407 295.500000 10933.5000 0.0000
P 2880 2785.156640 126913.1602 126702.1600
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 1883 15131.500000 21136.9400 21136.9400
T 1537 10542.740223 17880.8367 17858.3400
15709 27217.853107 308995.2409 0.0000
Other 35 37.000000 1848.6400 0.0000
---------------------------------------------------------
Total 22460 56017.249970 488050.8178 165697.4400
Center 54
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 1 0.250000 9.2500 0.0000
U 0 0.000000 0.0000 0.0000
B 5572 4556.500000 199031.0800 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 9764 63569.776800 125498.2106 125498.2100
T 899 6499.000000 13302.5100 13265.5100
13847 14134.473198 308253.4492 0.0000
Other 2 3.000000 168.0000 0.0000
---------------------------------------------------------
Total 30088 88765.249998 646358.7498 138763.7200
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 14267 20139.914136 395952.1900 395952.1900
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 7 14.000000 1050.0000 0.0000
T 0 0.000000 0.0000 0.0000
9617 7479.857571 385782.5274 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 23893 27635.021707 782830.9674 395952.1900
Center 57
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 56 41.250000 1563.7500 0.0000
U 0 0.000000 0.0000 0.0000
B 1901 1835.000000 73327.0000 0.0000
P 1088 1051.500000 44534.2800 44497.2800
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 3618 27760.750000 255201.9900 255114.3700
4487 8116.250000 388836.8400 286472.6400
Other 25 33.500000 1075.0200 1075.0200
---------------------------------------------------------
Total 11322 39007.500000 770706.6200 593040.3000