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:TPIN
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 4 2.500000 92.5000 37.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 7 8.500000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 70 136.000000 5032.0000 37.0000
Subtotal (Total Children Is Unduplicated) 74 147.000000 5124.5000 34.8605
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Screening, Eval, and Assessment,Class #02
ASTE-ASTE-ASSISTIVE TECHNOLOGY EVAL 2 3.000000 145.5000 48.5000
AUDE-92552-PURE TONE AUDIOMETRY -AIR ONLY 9 9.000000 161.2800 17.9200
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 9 9.000000 113.4900 12.6100
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 10 10.000000 82.6000 8.2600
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 9 9.000000 227.7900 25.3100
AUDE-92582-CONDITIONED PLAY AUDIOMETRY 1 1.000000 34.9700 34.9700
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 6 6.000000 111.3000 18.5500
AUDE-92588-OTOACOUSTIC EMISSIONS (COMP) 2 2.000000 41.3600 20.6800
AUDE-V5010-ASSESSMENT FOR HEARING AID 4 4.000000 180.0000 45.0000
AUDE-V5090-DISPENSING FEE PER HEARING AID 5 7.000000 805.0000 115.0000
EVAL-96111-DEVELOPMENTAL EVALUATION 1 2.000000 100.0000 50.0000
EXIT-EXIT-EXIT ASSESSMENT 5 5.250000 262.5000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 36 63.566667 4507.5000 70.9098
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 11 22.000000 1605.0000 72.9545
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 5 8.500000 637.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 20 32.000000 2350.0000 73.4375
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 25 44.500000 2331.2700 52.3881
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 382 706.429470 51043.1700 72.2552
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 153 276.468267 19790.0500 71.5816
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 141 230.966667 17083.3300 73.9645
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 391 705.500000 38564.5700 54.6627
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 186 289.000000 21587.7800 74.6982
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 15 15.000000 4347.2200 289.8147
NUTR-97803-NUTRITIONAL EVAL, FOLLOW-UP 11 44.000000 2200.0000 50.0000
OCTF-97168-OT RE-EVAL EST PLAN CARE 1 1.000000 51.0500 51.0500
OCTH-97165-OT EVAL LOW COMPLEXITY 6 6.000000 306.3000 51.0500
OCTH-97166-OT EVAL MODERATE COMPLEXITY 13 15.000000 765.7500 51.0500
OCTH-97167-OT EVAL HIGH COMPLEXITY 23 24.000000 1225.2000 51.0500
PSTF-97164-PT RE-EVAL EST PLAN CARE 2 2.000000 102.1000 51.0500
PSTH-97161-PT EVAL LOW COMPLEXITY 1 1.000000 23.8600 23.8600
PSTH-97162-PT EVAL MODERATE COMPLEXITY 6 7.000000 306.3000 43.7571
PSTH-97163-PT EVAL HIGH COMPLEXITY 19 19.000000 933.3300 49.1226
SCREEN-T1023-SCREENING 11 11.000000 550.0000 50.0000
SPCH-92522-EVAL OF SPCH SOUND PROD 1 1.000000 51.0500 51.0500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 65 65.727522 3304.3400 50.2733
SPCH-92524-BEHAV & QUAL ANALYSIS OF
VOICE AND RES 8 8.000000 408.4000 51.0500
Subtotal (Total Children Is Unduplicated) 921 2665.908593 176340.8600 66.1466
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 5 5.000000 4688.1200 937.6240
AUD-92592TS-AUDIOLOGY SERVICES (Monaural) 1 1.000000 50.0000 50.0000
AUD-92593TS-AUDIOLOGY SERVICES (Biaural) 1 1.000000 11.8900 11.8900
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 39 39.500000 1975.0000 50.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 127 169.250000 8462.5000 50.0000
CONIP-CONIP-CONSULT, ITDS PHONE 1 1.000000 25.0000 25.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 37 44.000000 2200.0000 50.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 17 17.500000 875.0000 50.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 15 17.000000 850.0000 50.0000
COUN-H2019HR-INDIVIDUAL/FAMILY THERAPY 1 1.000000 73.3200 73.3200
DSTT-DSTT-DIRECT SERVICE COORDINATOR TRAVEL 17 20.250000 0.0000 0.0000
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 1 1.000000 25.0000 25.0000
EIIF-96154-HEALTH AND BEHAVIOR INTERVENTION 3 39.500000 1975.0000 50.0000
EIIF-EIIF_NM-EI INDIVIDUAL SESSION BY NONMED PROF 1 5.000000 207.0000 41.4000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 1100 6634.320000 329413.5000 49.6529
INTR-T1013-INTERPRETER 35 333.500000 10436.2500 31.2931
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 312 801.000000 8010.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 328 1552.965527 106509.7200 68.5847
OCCT-97530HM-OT SESSION BY OT ASST 93 450.815949 26015.4800 57.7075
PHY-97110-PT SESSION BY LICENSED PT 366 1893.407370 122763.2600 64.8372
PHY-97110HM-PT SESSION BY PT ASST 26 128.893896 7367.5700 57.1600
SENS-V5050-IN EAR MONAURAL HEARING AID 4 6.000000 1368.0000 228.0000
SENS-V5060-BEHIND EAR HEARING AID
1 1.000000 228.0000 228.0000
SENS-V5264-EARMOLD 7 11.000000 198.0000 18.0000
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 954 5266.093614 364582.8900 69.2321
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 2 15.500000 886.6000 57.2000
SPL-92508-GROUP SPL SESSION PER CHILD 10 92.000000 1001.7600 10.8887
TRAV-TRAVS-Travel by mile 278 12181.00000 5422.2000 0.4451
Subtotal (Total Children Is Unduplicated) 2665 29729.49636 1005621.0600 33.8257
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Total 32542.404949 1187086.4200 36.4781
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Number of Children (Unduplicated) With at Least One Service 3239
-----------------------------------------------------------------------------------------------------------------------
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 1995 2014.250000 111865.6100 111865.6100
D 247 248.000000 14663.2900 0.0000
S 0 0.000000 0.0000 0.0000
H 260 280.000000 19178.0600 0.0000
T 68 66.750000 3975.4400 3975.4400
134 162.000000 10658.0000 0.0000
Other 15 24.000000 1669.6900 0.0000
---------------------------------------------------------
Total 2719 2795.000000 162010.0900 115841.0500
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 299 289.000000 20171.0900 20171.0900
0 0.000000 0.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 299 289.000000 20171.0900 20171.0900
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
2174 13821.000000 52473.6400 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 2174 13821.000000 52473.6400 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 44 106.500000 7430.1900 7430.1900
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 1 5.000000 357.2000 0.0000
T 0 0.000000 0.0000 0.0000
57 61.000000 7771.2500 0.0000
Other 81 197.500000 13076.0300 336.8100
---------------------------------------------------------
Total 183 370.000000 28634.6700 7767.0000
Center 05
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 0 0.000000 0.0000 0.0000
P 138 220.500000 15538.5900 15538.5900
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 138 220.500000 15538.5900 15538.5900
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 1993 1660.000000 90615.9600 90615.9600
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
1567 1475.500000 84793.6400 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 3560 3135.500000 175409.6000 90615.9600
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 126 237.260000 15814.1100 15814.1100
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 126 237.260000 15814.1100 15814.1100
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 399 859.500000 50477.2400 50622.4500
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
304 732.250000 50565.1800 0.0000
Other 33 52.000000 3831.7500 0.0000
---------------------------------------------------------
Total 752 1663.750000 106273.8800 50622.4500
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 205 375.000000 22719.9900 22719.9900
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
418 937.750000 63230.2900 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 623 1312.750000 85950.2800 22719.9900
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 276 949.500000 64757.1500 64757.1500
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
49 128.000000 8935.1700 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 325 1077.500000 73692.3200 64757.1500
Center 52
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 5 4.000000 148.0000 0.0000
P 74 88.750000 5944.6800 4588.1800
D 71 95.000000 5030.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 69 106.250000 7090.6100 0.0000
T 802 1397.500000 85023.3500 76508.6300
231 361.000000 21041.2900 148.0500
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 1252 2052.500000 124277.9300 81244.8600
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 25 28.673380 1702.5498 797.6200
D 4 5.000000 295.7500 0.0000
S 0 0.000000 0.0000 0.0000
H 34 35.000000 2211.2400 2211.2400
T 10 10.000000 564.3200 564.3200
718 758.326620 40218.7602 0.0000
Other 15 18.500000 1065.6300 0.0000
---------------------------------------------------------
Total 806 855.500000 46058.2500 3573.1800
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 92 92.250000 4935.2700 4935.2700
T 21 22.000000 1223.7000 1223.7000
866 872.110000 46270.8900 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 979 986.360000 52429.8600 6158.9700
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 714 661.255200 45541.3900 45541.3900
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 408 365.250000 24990.3500 24990.3500
817 664.416349 44837.0300 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 1940 1692.921549 115518.7700 70531.7400
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 20 10.863400 755.6900 755.6900
D 0 0.000000 0.0000 0.0000
S 24 14.000000 915.4500 915.4500
H 0 0.000000 0.0000 0.0000
T 425 1385.500000 70999.2900 70999.2900
271 622.500000 40162.9100 38828.4100
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 740 2032.863400 112833.3400 111498.8400