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
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 10735 11582.00000 428450.7500 36.9928
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 7578 7517.500000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 7082 20919.50000 773699.7500 36.9846
Subtotal (Total Children Is Unduplicated) 16839 40019.00000 1202150.5000 30.0395
-----------------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
ASTE-ASTE-ASSISTIVE TECHNOLOGY EVAL 29 29.000000 1391.6300 47.9872
AUD-92626-EVAL OF AUD REHAB STATUS 1 1.000000 51.3500 51.3500
AUDE-92552-PURE TONE AUDIOMETRY -AIR ONLY 47 49.000000 878.0800 17.9200
AUDE-92553-PURE TONE AUDIOMETRY AIR & BONE 1 1.000000 21.3500 21.3500
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 52 54.000000 680.9400 12.6100
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 54 56.000000 462.5600 8.2600
AUDE-92568-ACOUSTIC REFLEX TESTING (MEMR) 2 2.000000 18.1200 9.0600
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 58 60.000000 1518.6000 25.3100
AUDE-92582-CONDITIONED PLAY AUDIOMETRY 1 1.000000 34.9700 34.9700
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 26 26.000000 482.3000 18.5500
AUDE-92588-OTOACOUSTIC EMISSIONS (COMP) 4 5.000000 103.4000 20.6800
AUDE-V5010-ASSESSMENT FOR HEARING AID 5 5.000000 225.0000 45.0000
AUDE-V5090-DISPENSING FEE PER HEARING AID 5 9.000000 1035.0000 115.0000
EVAL-96111-DEVELOPMENTAL EVALUATION 68 79.500000 3975.0000 50.0000
EXIT-EXIT-EXIT ASSESSMENT 762 1248.000000 62337.5000 49.9499
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 39 47.933333 3585.0000 74.7914
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 10 11.000000 825.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 6 11.500000 862.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 29 36.000000 2700.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 53 62.000000 3441.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 437 628.570530 46508.9900 73.9917
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 112 163.531733 12157.9600 74.3462
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 147 223.800000 16747.5000 74.8324
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 685 915.500000 50548.2400 55.2138
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 313 468.000000 34781.6200 74.3197
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 45 45.000000 2409.7500 53.5500
MED-99204-OUTPATIENT VISIT, NEW, 45 MINS 4 4.000000 302.8800 75.7200
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 5 5.000000 133.0500 26.6100
NUTR-97803-NUTRITIONAL EVAL, FOLLOW-UP 15 29.000000 1450.0000 50.0000
OCTF-97168-OT RE-EVAL EST PLAN CARE 7 7.000000 357.3500 51.0500
OCTH-97165-OT EVAL LOW COMPLEXITY 4 6.000000 306.3000 51.0500
OCTH-97166-OT EVAL MODERATE COMPLEXITY 21 21.000000 1072.0500 51.0500
OCTH-97167-OT EVAL HIGH COMPLEXITY 40 40.000000 2039.4500 50.9863
PSTF-97164-PT RE-EVAL EST PLAN CARE 9 9.000000 459.4500 51.0500
PSTH-97161-PT EVAL LOW COMPLEXITY 3 3.000000 153.1500 51.0500
PSTH-97162-PT EVAL MODERATE COMPLEXITY 6 6.000000 232.2700 38.7117
PSTH-97163-PT EVAL HIGH COMPLEXITY 23 25.000000 1250.7200 50.0288
SCREEN-T1023-SCREENING 8 8.000000 400.0000 50.0000
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 82 81.272478 4148.9600 51.0500
SPCH-92524-BEHAV & QUAL ANALYSIS OF
VOICE AND RES 8 8.000000 408.4000 51.0500
Subtotal (Total Children Is Unduplicated) 2231 4490.608074 260497.3900 58.0094
-----------------------------------------------------------------------------------------------------------------------
EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 28 43.000000 27598.9200 641.8353
AUD-92593TS-AUDIOLOGY SERVICES (Biaural) 3 3.000000 150.0000 50.0000
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 1372 1616.250000 80297.5000 49.6814
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 67 46.250000 1156.2500 25.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 1977 3386.250000 169085.0000 49.9328
CONIP-CONIP-CONSULT, ITDS PHONE 161 166.250000 4156.2500 25.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 412 677.750000 33887.5000 50.0000
CONOP-CONOP-CONSULT, OT, PHONE 26 48.500000 1212.5000 25.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 287 343.000000 17150.0000 50.0000
CONPP-CONPP-CONSULT, PT, PHONE 4 1.750000 43.7500 25.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 1168 1351.750000 67587.5000 50.0000
CONSP-CONSP-CONSULT, SLP, PHONE 63 82.250000 2056.2500 25.0000
COUN-H2019HR-INDIVIDUAL/FAMILY THERAPY 7 13.000000 953.1600 73.3200
DSTT-DSTT-DIRECT SERVICE COORDINATOR TRAVEL 1511 4686.250000 0.0000 0.0000
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 45 182.750000 4568.7500 25.0000
EIIF-EIIF_NM-EI INDIVIDUAL SESSION BY NONMED PROF 13 69.750000 3487.5000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 2547 16655.68000 831214.2000 49.9057
INTR-T1013-INTERPRETER 419 1606.500000 73679.7500 45.8635
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 12850 111311.0000 1092528.9300 9.8151
OCCT-97530-OT SESSION BY LICENSED OT 467 2281.150273 161276.1200 70.6995
OCCT-97530HM-OT SESSION BY OT ASST 96 506.434451 28967.8200 57.1995
PHY-97110-PT SESSION BY LICENSED PT 439 2242.102630 155210.1900 69.2253
PHY-97110HM-PT SESSION BY PT ASST 45 309.606104 17697.0900 57.1600
SENS-V5050-IN EAR MONAURAL HEARING AID 4 8.000000 1824.0000 228.0000
SENS-V5264-EARMOLD 7 14.000000 252.0000 18.0000
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 1010 5693.957100 398633.2101 70.0099
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 2 26.500000 1515.8000 57.2000
SPL-92508-GROUP SPL SESSION PER CHILD 10 180.500000 2380.8400 13.1902
TRAV-TRAVS-Travel by mile 5592 536808.0000 237489.7700 0.4424
Subtotal (Total Children Is Unduplicated) 15059 690361.1806 3416060.5501 4.9482
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
Payclass Filters:GR
Eligibility Filter:Part C (excluding not eligible)
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
-----------------------------------------------------------------------------------------------------------------------
Total 734870.788632 4878708.4401 6.6389
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 21673
-----------------------------------------------------------------------------------------------------------------------
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 17416 75893.750000 267894.6000 267894.6000
D 751 4853.500000 13031.0100 0.0000
S 2 0.500000 18.5000 0.0000
H 0 0.000000 0.0000 0.0000
T 1153 7346.750000 15746.0400 15746.0400
5623 3863.000000 109404.9500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 24945 91957.500000 406095.1000 283640.6400
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 4305 10967.250000 102421.1900 102060.5900
1 1.000000 71.4400 51.0500
Other 2980 12178.250000 49400.2300 0.0000
---------------------------------------------------------
Total 7286 23146.500000 151892.8600 102111.6400
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
13656 71420.750000 265447.9500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 13656 71420.750000 265447.9500 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 3652 14716.750000 254401.0100 254189.4100
D 44 65.500000 2423.5000 0.0000
S 0 0.000000 0.0000 0.0000
H 8 26.000000 620.0000 170.0000
T 0 0.000000 0.0000 0.0000
2752 2522.000000 102461.6400 0.0000
Other 5 4.000000 182.4900 60.0000
---------------------------------------------------------
Total 6461 17334.250000 360088.6400 254419.4100
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 5394 65923.000000 167503.2700 167500.1540
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
2468 1563.750000 42161.1900 63.8000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 7862 67486.750000 209664.4600 167563.9540
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 6743 6606.750000 99238.9600 99238.9600
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
11912 8792.750000 193566.1500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 18655 15399.500000 292805.1100 99238.9600
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 2900 6359.000000 137745.2100 137745.2100
D 189 144.250000 5898.0000 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
5876 3792.750000 116577.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 8965 10296.000000 260220.2100 137745.2100
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 13445 119808.500000 556581.4500 556581.4500
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
40 87.500000 2851.2200 0.0000
Other 2 4.000000 261.0000 0.0000
---------------------------------------------------------
Total 13487 119900.000000 559693.6700 556581.4500
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 9896 30571.250000 748242.8400 748242.8400
D 43 25.250000 934.2500 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
6096 4785.750000 156136.2500 60.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 16035 35382.250000 905313.3400 748302.8400
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 1429 10955.000000 79021.7200 79039.7200
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
2780 2657.250000 68939.1000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 4209 13612.250000 147960.8200 79039.7200
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 3 3.000000 110.0000 110.0000
D 11 10.250000 530.3500 0.0000
S 3 1.500000 55.5000 0.0000
H 0 0.000000 0.0000 0.0000
T 6246 58008.250000 167668.5000 164808.9600
2884 1731.500000 42036.0100 174.0100
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 9147 59754.500000 210400.3600 165092.9700
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 4558 32320.250000 55133.5500 55133.5500
T 1674 11665.750000 20021.8500 20021.8500
10979 17654.250000 142721.8800 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 17211 61640.250000 217877.2800 75155.4000
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 6143 40696.570000 77484.6800 77484.6800
T 3261 23411.250000 39668.9700 39246.7400
14948 40022.820000 172410.1600 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 24352 104130.640000 289563.8100 116731.4200
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 7163 12495.881670 146462.7801 146462.7800
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 3059 6110.766431 66355.1800 66355.1800
4366 2601.000531 87749.2900 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 14588 21207.648632 300567.2501 212817.9600
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 15 20.250000 805.7500 0.0000
S 72 66.250000 2477.3700 2478.4200
H 0 0.000000 0.0000 0.0000
T 3420 19768.750000 201926.9600 201925.1300
2472 2341.750000 95857.5000 255.2500
Other 2 5.000000 50.0000 50.0000
---------------------------------------------------------
Total 5981 22202.000000 301117.5800 204708.8000