CMS/EIP Fiscal Report Statewide
Services beginning 10/01/2017 ending 12/31/2017 Date of Report:02/03/2018 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 10737 11584.50000 428543.2500 36.9928
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 7582 7526.000000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 20808 61869.75000 2287538.7400 36.9735
Subtotal (Total Children Is Unduplicated) 21962 80980.25000 2716081.9900 33.5401
-----------------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
ASTE-ASTE-ASSISTIVE TECHNOLOGY EVAL 31 32.000000 1537.1300 48.0353
AUD-92626-EVAL OF AUD REHAB STATUS 1 1.000000 51.3500 51.3500
AUDE-92552-PURE TONE AUDIOMETRY -AIR ONLY 56 58.000000 1039.3600 17.9200
AUDE-92553-PURE TONE AUDIOMETRY AIR & BONE 1 1.000000 21.3500 21.3500
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 61 63.000000 794.4300 12.6100
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 64 66.000000 545.1600 8.2600
AUDE-92568-ACOUSTIC REFLEX TESTING (MEMR) 2 2.000000 18.1200 9.0600
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 67 69.000000 1746.3900 25.3100
AUDE-92582-CONDITIONED PLAY AUDIOMETRY 2 2.000000 69.9400 34.9700
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 32 32.000000 593.6000 18.5500
AUDE-92588-OTOACOUSTIC EMISSIONS (COMP) 6 7.000000 144.7600 20.6800
AUDE-V5010-ASSESSMENT FOR HEARING AID 10 10.000000 450.0000 45.0000
AUDE-V5090-DISPENSING FEE PER HEARING AID 11 17.000000 1955.0000 115.0000
EVAL-96111-DEVELOPMENTAL EVALUATION 68 81.500000 4075.0000 50.0000
EXIT-EXIT-EXIT ASSESSMENT 779 1279.250000 63900.0000 49.9511
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 158 258.500000 19117.5000 73.9555
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 81 127.000000 9480.0000 74.6457
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 34 52.500000 3937.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 95 152.000000 11330.5000 74.5428
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 181 295.500000 16261.7700 55.0314
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 1991 3179.500000 235708.2800 74.1338
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 837 1324.000000 98248.0100 74.2054
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 640 1010.766667 75530.8300 74.7263
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 2470 3844.000000 212415.0600 55.2589
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 1155 1766.500000 132081.9000 74.7704
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 96 96.000000 8684.7700 90.4664
MED-99204-OUTPATIENT VISIT, NEW, 45 MINS 4 4.000000 302.8800 75.7200
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 13 13.000000 345.9300 26.6100
MED-99214-OUTPATIENT VISIT, EST, 25 MINS 1 1.000000 41.4600 41.4600
NUTR-97803-NUTRITIONAL EVAL, FOLLOW-UP 27 134.000000 6700.0000 50.0000
OCTF-97168-OT RE-EVAL EST PLAN CARE 20 20.000000 1021.0000 51.0500
OCTH-97165-OT EVAL LOW COMPLEXITY 12 14.000000 714.7000 51.0500
OCTH-97166-OT EVAL MODERATE COMPLEXITY 39 41.000000 2093.0500 51.0500
OCTH-97167-OT EVAL HIGH COMPLEXITY 102 103.000000 5255.6000 51.0252
PSTF-97164-PT RE-EVAL EST PLAN CARE 19 19.000000 969.9500 51.0500
PSTH-97161-PT EVAL LOW COMPLEXITY 4 4.000000 177.0100 44.2525
PSTH-97162-PT EVAL MODERATE COMPLEXITY 15 16.000000 691.7200 43.2325
PSTH-97163-PT EVAL HIGH COMPLEXITY 84 86.000000 4328.1500 50.3273
SCREEN-T1023-SCREENING 64 66.000000 3300.0000 50.0000
SPCH-92521-EVAL OF SPEECH FLUENCY 1 1.000000 51.0500 51.0500
SPCH-92522-EVAL OF SPCH SOUND PROD 1 1.000000 51.0500 51.0500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 202 203.000000 10311.0500 50.7933
SPCH-92524-BEHAV & QUAL ANALYSIS OF
VOICE AND RES 23 23.000000 1174.1500 51.0500
Subtotal (Total Children Is Unduplicated) 5233 14576.01667 937266.4600 64.3020
-----------------------------------------------------------------------------------------------------------------------
EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 33 48.000000 32287.0400 672.6467
AUD-92592TS-AUDIOLOGY SERVICES (Monaural) 1 1.000000 50.0000 50.0000
AUD-92593TS-AUDIOLOGY SERVICES (Biaural) 4 4.000000 161.8900 40.4725
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 1418 1682.750000 83622.5000 49.6940
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 70 48.000000 1200.0000 25.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 2042 3564.500000 177997.5000 49.9362
CONIP-CONIP-CONSULT, ITDS PHONE 163 168.750000 4218.7500 25.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 421 728.750000 36437.5000 50.0000
CONOP-CONOP-CONSULT, OT, PHONE 26 48.500000 1212.5000 25.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 297 363.250000 18162.5000 50.0000
CONPP-CONPP-CONSULT, PT, PHONE 4 1.750000 43.7500 25.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 1186 1383.250000 69162.5000 50.0000
CONSP-CONSP-CONSULT, SLP, PHONE 63 82.750000 2068.7500 25.0000
COUN-H2019HR-INDIVIDUAL/FAMILY THERAPY 11 20.000000 1466.4000 73.3200
DSTT-DSTT-DIRECT SERVICE COORDINATOR TRAVEL 1598 4877.000000 35.7200 0.0073
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 141 6337.750000 158443.7500 25.0000
EIIF-96154-HEALTH AND BEHAVIOR INTERVENTION 3 39.500000 1975.0000 50.0000
EIIF-EIIF_NM-EI INDIVIDUAL SESSION BY NONMED PROF 14 74.750000 3694.5000 49.4247
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 8809 66390.75000 3315197.7000 49.9346
INTR-T1013-INTERPRETER 431 1940.000000 84116.0000 43.3588
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 12873 112266.0000 1102078.9300 9.8167
OCCT-97530-OT SESSION BY LICENSED OT 1039 5625.934100 395644.7800 70.3252
OCCT-97530HM-OT SESSION BY OT ASST 316 1719.750400 98598.3000 57.3329
PHY-97110-PT SESSION BY LICENSED PT 1069 5867.010000 401247.1600 68.3904
PHY-97110HM-PT SESSION BY PT ASST 186 1208.500000 69077.8600 57.1600
SENS-V5050-IN EAR MONAURAL HEARING AID 9 15.000000 3420.0000 228.0000
SENS-V5060-BEHIND EAR HEARING AID
1 1.000000 228.0000 228.0000
CMS/EIP Fiscal Report Statewide
Services beginning 10/01/2017 ending 12/31/2017 Date of Report:02/03/2018 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
SENS-V5264-EARMOLD 15 26.000000 468.0000 18.0000
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 2406 14875.30071 1041646.1201 70.0252
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 28 90.000000 5148.0000 57.2000
SPL-92508-GROUP SPL SESSION PER CHILD 35 314.000000 3958.6200 12.6071
TRAV-TRAVS-Travel by mile 5696 577393.0000 255483.2000 0.4425
Subtotal (Total Children Is Unduplicated) 15688 807206.4952 7368553.2201 9.1285
-----------------------------------------------------------------------------------------------------------------------
Total 902762.761881 11021901.6701 12.2091
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 24084
-----------------------------------------------------------------------------------------------------------------------
Center 01
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 3 0.750000 27.7500 0.0000
U 0 0.000000 0.0000 0.0000
B 7275 4870.250000 192545.4600 0.0000
P 19513 78012.500000 385118.0100 385118.0100
D 1177 5283.250000 39591.8500 0.0000
S 164 139.250000 7080.9300 0.0000
H 260 280.000000 19178.0600 0.0000
T 1221 7413.500000 19721.4800 19721.4800
5839 4125.500000 126632.3100 0.0000
Other 208 259.500000 15790.6600 0.0000
---------------------------------------------------------
Total 35660 100384.500000 805686.5100 404839.4900
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 4604 11256.250000 122592.2800 122231.6800
1 1.000000 71.4400 51.0500
Other 4485 13326.000000 100422.2300 0.0000
---------------------------------------------------------
Total 9090 24583.250000 223085.9500 122282.7300
Center 03
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 22 27.750000 1377.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 2770 1725.250000 69056.2500 0.0000
P 0 0.000000 0.0000 0.0000
D 0 0.000000 0.0000 0.0000
S 1 1.750000 64.7500 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
15831 85242.750000 317971.5900 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 18624 86997.500000 388470.0900 0.0000
Center 04
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 40 45.750000 1692.7500 0.0000
U 0 0.000000 0.0000 0.0000
B 579 888.000000 34253.0000 0.0000
P 6357 18962.250000 423252.7900 423154.1900
D 44 65.500000 2423.5000 0.0000
S 1 3.000000 111.0000 0.0000
H 2555 10435.500000 530386.2700 170.0000
T 0 0.000000 0.0000 0.0000
3634 9187.250000 313315.1100 0.0000
Other 86 201.500000 13258.5200 396.8100
---------------------------------------------------------
Total 13296 39788.750000 1318692.9400 423721.0000
Center 05
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 2573 1603.250000 64004.5000 0.0000
P 5535 66146.500000 183191.8600 183188.7440
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
2470 1564.500000 42188.9400 63.8000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 10578 69314.250000 289385.3000 183252.5440
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 8736 8266.750000 189854.9200 189854.9200
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
17960 13567.000000 415632.2300 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 26696 21833.750000 605487.1500 189854.9200
Center 07
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 19 12.500000 538.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 8 7.250000 496.2500 0.0000
P 7713 10248.760000 302882.3200 302882.3200
D 189 144.250000 5898.0000 0.0000
S 5 9.500000 364.5000 0.0000
H 0 0.000000 0.0000 0.0000
T 1 0.500000 18.5000 0.0000
5892 3800.250000 116880.5000 0.0000
Other 2 0.500000 18.5000 0.0000
---------------------------------------------------------
Total 13829 14223.510000 427097.0700 302882.3200
Center 09
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 56 61.750000 3084.7500 0.0000
P 19685 153988.250000 871499.7600 871673.2270
D 16 20.000000 1399.7100 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
2414 8025.500000 410910.4000 0.0000
Other 178 283.000000 20679.0000 0.0000
---------------------------------------------------------
Total 22349 162378.500000 1307573.6200 871673.2270
Center 10
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 31 15.000000 555.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 8880 7014.750000 295890.0000 0.0000
P 10101 30946.250000 770962.8300 770962.8300
D 43 25.250000 934.2500 0.0000
S 10 17.750000 1204.7500 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
9814 17521.000000 822840.9500 60.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 28879 55540.000000 1892387.7800 771022.8300
Center 51
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 3 2.000000 74.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 1338 866.250000 33763.5000 0.0000
P 1708 11912.500000 144243.1900 144161.1900
D 9 5.500000 203.5000 0.0000
S 1 0.500000 18.5000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
3531 4777.250000 195494.0900 0.0000
Other 1 0.500000 18.5000 0.0000
---------------------------------------------------------
Total 6591 17564.500000 373815.2800 144161.1900
Center 52
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 71 77.750000 4126.2500 37.0000
P 2914 2660.250000 127487.4300 124822.7300
D 141 155.250000 8247.9600 0.0000
S 33 27.000000 1221.0000 0.0000
H 122 156.250000 10507.5900 0.0000
T 7053 59431.750000 253031.7500 241442.4900
3958 3739.750000 160368.4500 322.0600
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 14292 66248.000000 564990.4300 366624.2800
Center 53
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 947 870.500000 38154.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 214 153.250000 6103.0000 0.0000
P 1573 1571.673380 71166.2998 70261.3700
D 4 5.000000 295.7500 0.0000
S 0 0.000000 0.0000 0.0000
H 4592 32355.250000 57344.7900 57344.7900
T 1684 11675.750000 20586.1700 20586.1700
14530 21294.076620 326190.7002 0.0000
Other 17 20.500000 1139.6300 0.0000
---------------------------------------------------------
Total 23561 67946.000000 520980.8400 148192.3300
Center 54
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 1385 1119.750000 47042.2500 0.0000
U 0 0.000000 0.0000 0.0000
B 3048 2463.750000 108226.8500 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 6235 40788.820000 82419.9500 82419.9500
T 3282 23433.250000 40892.6700 40470.4400
20825 45803.180000 459434.2900 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 34775 113608.750000 738016.0100 122890.3900
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 0.750000 27.7500 0.0000
P 11376 16117.636870 310791.9201 310791.9200
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 1 2.000000 150.0000 0.0000
T 3467 6476.016431 91345.5300 91345.5300
9109 6912.666880 357320.9800 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 23955 29509.070181 759636.1801 402137.4500
Center 57
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 2431 2486.750000 99109.7500 0.0000
P 264 224.613400 10659.5800 10659.6300
D 15 20.250000 805.7500 0.0000
S 96 80.250000 3392.8200 3393.8700
H 0 0.000000 0.0000 0.0000
T 3847 21160.250000 273226.2500 273224.4200
4285 8654.318300 414538.1600 317184.8300
Other 103 216.000000 4864.2100 4904.2100
---------------------------------------------------------
Total 11041 32842.431700 806596.5200 609366.9600