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: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 8249 9487.250000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 7534 22153.75000 819183.0000 36.9772
Subtotal (Total Children Is Unduplicated) 18176 43717.25000 1265802.7500 28.9543
-----------------------------------------------------------------------------------------------------------------------
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 101 127.250000 6358.2500 49.9666
EXIT-EXIT-EXIT ASSESSMENT 759 1225.500000 61200.0000 49.9388
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 24 28.517200 2138.7900 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 10 14.000000 1050.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 11 13.990223 1049.2667 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 32 39.000000 2164.5000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 437 577.744428 42890.1700 74.2373
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 145 182.253566 13669.0200 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 148 212.000000 15752.0000 74.3019
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 748 941.000000 52015.8700 55.2772
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 269 387.500000 29025.0000 74.9032
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 11 11.000000 589.0500 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) 2269 4276.983909 247727.5467 57.9211
-----------------------------------------------------------------------------------------------------------------------
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 1202 1529.250000 73837.5000 48.2835
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 67 50.500000 1262.5000 25.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 1908 3269.000000 163284.2500 49.9493
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 1220 2363.000000 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 2481 14706.60000 734437.9800 49.9393
INTR-T1013-INTERPRETER 425 1732.000000 78758.1900 45.4724
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 13081 100006.0000 1003081.0000 10.0302
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:Program Patients
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 5556 477542.0000 210771.7100 0.4414
Subtotal (Total Children Is Unduplicated) 15322 614525.7886 3136938.3064 5.1046
-----------------------------------------------------------------------------------------------------------------------
Total 662520.022488 4650468.6031 7.0194
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 22998
-----------------------------------------------------------------------------------------------------------------------
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 15013 68023.500000 225850.6900 225850.6900
D 696 3242.500000 13094.7500 0.0000
S 4 18.500000 98.7500 6.2500
H 0 0.000000 0.0000 0.0000
T 1956 9597.750000 24795.6100 24795.6100
6347 4205.250000 124417.7700 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 24016 85087.500000 388257.5700 250652.5500
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 4606 12597.500000 111994.3000 111335.0300
112 257.500000 2546.0800 0.0000
Other 3445 15302.750000 54025.0600 0.0000
---------------------------------------------------------
Total 8163 28157.750000 168565.4400 111335.0300
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
17321 86759.000000 346186.1300 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 17321 86759.000000 346186.1300 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
3308 3071.000000 123939.5100 0.0000
Other 7 16.000000 848.4100 297.2800
---------------------------------------------------------
Total 6788 16199.500000 352238.3400 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 4379 51761.750000 136886.3600 136526.6780
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
3057 1733.750000 49257.1100 82.8900
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 7436 53495.500000 186143.4700 136609.5680
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 6322 6210.000000 96104.3300 96104.3300
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
11645 8400.500000 195602.7100 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 17967 14610.500000 291707.0400 96104.3300
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 3203 7604.250000 150501.3700 150501.3700
D 163 107.500000 4362.2500 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
6511 4142.250000 121025.5000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 9877 11854.000000 275889.1200 150501.3700
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 12027 92240.750000 457056.7100 457056.7100
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
106 870.250000 4826.8100 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 12133 93111.000000 461883.5200 457056.7100
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 7953 23816.750000 604488.2900 604488.2900
D 124 64.250000 2377.2500 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
5858 4349.750000 138471.2500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 13935 28230.750000 745336.7900 604488.2900
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 1686 5266.500000 107539.6800 107539.6800
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
2758 1940.000000 69437.8900 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 4448 7209.250000 177105.3200 107539.6800
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 6162 57637.000000 169171.0900 166463.8500
3102 2044.500000 43814.3800 186.7500
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 9269 59698.500000 213206.0200 166746.8300
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 1870 15118.500000 20486.9400 20486.9400
T 1525 10529.740223 17180.8367 17158.3400
12658 24155.250000 151160.7600 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 16053 49803.490223 188828.5367 37645.2800
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 9670 63473.910000 120124.8664 120124.8700
T 884 6484.500000 12470.3100 12433.3100
10057 10175.000000 111255.7900 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 20611 80133.410000 243850.9664 132558.1800
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 9461 15748.914136 198209.2200 198209.2200
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
4838 2942.458129 99459.6100 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 14299 18691.372265 297668.8300 198209.2200
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 3358 26873.750000 208530.9500 208443.3300
2749 2446.000000 99631.5000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 6234 29478.500000 313601.5100 213595.6400