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: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 11485 12267.25000 453805.0000 36.9932
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 8268 8275.750000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 22231 67461.50000 2494204.2400 36.9723
Subtotal (Total Children Is Unduplicated) 23420 88004.50000 2948009.2400 33.4984
-----------------------------------------------------------------------------------------------------------------------
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 69 83.500000 4175.0000 50.0000
EXIT-EXIT-EXIT ASSESSMENT 780 1280.250000 63950.0000 49.9512
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 187 304.000000 22530.0000 74.1118
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 89 141.500000 10567.5000 74.6820
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 39 59.500000 4462.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 114 184.500000 13805.5000 74.8266
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 218 354.500000 19536.2700 55.1094
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 2519 4006.500000 296891.7100 74.1025
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 1068 1670.000000 124014.2600 74.2600
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 788 1238.266667 92375.8500 74.6009
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 3136 4842.000000 267600.5600 55.2665
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 1491 2245.000000 168091.7400 74.8738
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 129 129.000000 12029.9600 93.2555
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) 6240 17647.51667 1146526.1900 64.9681
-----------------------------------------------------------------------------------------------------------------------
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 1419 1684.750000 83722.5000 49.6943
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 70 48.000000 1200.0000 25.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 2046 3571.500000 178347.5000 49.9363
CONIP-CONIP-CONSULT, ITDS PHONE 164 169.750000 4243.7500 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 1813 5161.500000 35.7200 0.0069
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 8816 66429.75000 3317147.7000 49.9347
INTR-T1013-INTERPRETER 464 2023.000000 88058.5000 43.5287
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 13150 112840.0000 1107818.9300 9.8176
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 1070 5868.010000 401318.6000 68.3909
PHY-97110HM-PT SESSION BY PT ASST 188 1221.500000 69820.9400 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:Program Patients
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 2407 14878.30071 1041860.4401 70.0255
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 5944 585237.0000 258967.4800 0.4425
Subtotal (Total Children Is Unduplicated) 16126 816057.9952 7385173.8401 9.0498
-----------------------------------------------------------------------------------------------------------------------
Total 921710.011881 11479709.2701 12.4548
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 25568
-----------------------------------------------------------------------------------------------------------------------
Center 01
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 4 2.750000 177.7500 0.0000
U 0 0.000000 0.0000 0.0000
B 7546 5116.000000 202441.9600 0.0000
P 19605 78712.750000 388468.0500 388468.0500
D 1179 5284.500000 39679.3500 0.0000
S 170 143.250000 7342.9300 0.0000
H 264 286.000000 19628.0600 0.0000
T 1221 7413.500000 19721.4800 19721.4800
6133 4361.250000 135233.0600 0.0000
Other 220 277.000000 16937.4100 0.0000
---------------------------------------------------------
Total 36342 101597.000000 829630.0500 408189.5300
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 4656 11907.750000 125662.4600 125308.8600
1 1.000000 71.4400 51.0500
Other 4816 14230.500000 108967.7100 0.0000
---------------------------------------------------------
Total 9473 26139.250000 234701.6100 125359.9100
Center 03
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 26 30.750000 1488.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 3053 2000.250000 81356.2500 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
16262 85571.250000 328181.0900 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 19342 87604.000000 411090.5900 0.0000
Center 04
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 44 61.250000 2266.2500 0.0000
U 0 0.000000 0.0000 0.0000
B 621 960.750000 37359.2500 0.0000
P 6646 19504.000000 445753.8100 445697.0900
D 48 75.500000 2793.5000 0.0000
S 2 5.000000 185.0000 0.0000
H 2558 10448.500000 531036.2700 170.0000
T 0 0.000000 0.0000 0.0000
4140 9702.000000 338689.2100 0.0000
Other 86 201.500000 13258.5200 396.8100
---------------------------------------------------------
Total 14145 40958.500000 1371341.8100 446263.9000
Center 05
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 2792 1787.750000 72294.0000 0.0000
P 5620 66951.000000 185320.3700 185317.2540
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
2606 1654.500000 44159.1900 63.8000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 11018 70393.250000 301773.5600 185381.0540
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
18435 13968.000000 432733.9800 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 27171 22234.750000 622588.9000 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 11 8.000000 524.0000 0.0000
P 8120 10736.760000 324056.8900 324056.8900
D 210 171.750000 7360.2500 0.0000
S 6 9.750000 373.7500 0.0000
H 0 0.000000 0.0000 0.0000
T 1 0.500000 18.5000 0.0000
6417 4245.750000 131171.0000 0.0000
Other 2 0.500000 18.5000 0.0000
---------------------------------------------------------
Total 14786 15185.510000 464061.3900 324056.8900
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 20254 155149.250000 906037.7900 906211.2570
D 17 22.000000 1510.7100 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
2431 8053.000000 412616.9000 0.0000
Other 228 356.500000 26084.2500 0.0000
---------------------------------------------------------
Total 22986 163642.500000 1349334.4000 906211.2570
Center 10
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 32 17.750000 656.7500 0.0000
U 0 0.000000 0.0000 0.0000
B 9267 7488.000000 318596.2500 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
10152 17942.250000 841986.9500 60.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 29605 56437.250000 1934341.7800 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 1377 901.500000 35234.2500 0.0000
P 1719 11923.500000 144658.6900 144576.6900
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
3635 4868.500000 199181.3400 0.0000
Other 1 0.500000 18.5000 0.0000
---------------------------------------------------------
Total 6745 17702.000000 379388.7800 144576.6900
Center 52
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 80 92.250000 5023.7500 37.0000
P 3129 2932.250000 140535.1800 137513.9700
D 149 169.500000 9046.9600 0.0000
S 41 34.750000 1507.7500 0.0000
H 148 205.750000 13732.5900 0.0000
T 7164 61032.750000 257030.7800 245208.7700
4297 4052.250000 173423.2400 472.0600
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 15008 68519.500000 600300.2500 383231.8000
Center 53
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 1048 972.750000 42853.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 238 175.250000 7001.7500 0.0000
P 1702 1732.834190 79392.8698 78128.6200
D 4 5.000000 295.7500 0.0000
S 0 0.000000 0.0000 0.0000
H 4673 32942.000000 58170.9400 58170.9400
T 1724 12117.250000 21157.2300 21157.2300
15442 22159.915810 349707.8002 0.0000
Other 20 24.750000 1409.8800 0.0000
---------------------------------------------------------
Total 24851 70129.750000 559989.7200 157456.7900
Center 54
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 1535 1276.500000 53894.2500 0.0000
U 0 0.000000 0.0000 0.0000
B 3381 2781.000000 123434.3500 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 6313 41568.320000 83472.0100 83472.0100
T 3370 24188.750000 42229.8400 41797.6100
21968 47553.430000 490377.1700 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 36567 117368.000000 793407.6200 125269.6200
Center 55
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 3 1.250000 46.2500 0.0000
P 11787 16647.764470 335205.9901 335205.9900
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 3 4.666667 350.0000 0.0000
T 3476 6494.016431 92617.5300 92617.5300
9651 7430.872613 382143.7400 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 24920 30578.570181 810363.5101 427823.5200
Center 57
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 2494 2567.000000 102851.0000 0.0000
P 269 231.113400 11041.3300 11041.3800
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 3862 21323.250000 273912.7800 273910.9500
4393 8782.318300 420527.4100 317967.8300
Other 103 216.000000 4864.2100 4904.2100
---------------------------------------------------------
Total 11232 33220.181700 817395.3000 611218.2400