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: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 11483 12264.75000 453712.5000 36.9932
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 8264 8267.250000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 7638 22938.50000 848328.7500 36.9827
Subtotal (Total Children Is Unduplicated) 18078 43470.50000 1302041.2500 29.9523
-----------------------------------------------------------------------------------------------------------------------
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 69 81.500000 4075.0000 50.0000
EXIT-EXIT-EXIT ASSESSMENT 763 1249.000000 62387.5000 49.9500
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 42 52.933333 3960.0000 74.8111
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 12 15.000000 1125.0000 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 33 42.000000 3150.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 57 66.500000 3690.7500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 542 781.999463 57822.6900 73.9421
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 144 210.531733 15682.9600 74.4921
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 169 258.300000 19285.0000 74.6612
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 841 1116.000000 61620.4900 55.2155
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 401 595.500000 44160.2600 74.1566
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 60 60.000000 3213.0000 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) 2504 5091.037007 300652.4800 59.0553
-----------------------------------------------------------------------------------------------------------------------
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 1373 1618.250000 80397.5000 49.6818
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 67 46.250000 1156.2500 25.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 1981 3393.250000 169435.0000 49.9330
CONIP-CONIP-CONSULT, ITDS PHONE 162 167.250000 4181.2500 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 1724 4965.750000 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 2549 16662.68000 831564.2000 49.9058
INTR-T1013-INTERPRETER 450 1682.250000 77384.7500 46.0007
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 13127 111885.0000 1098268.9300 9.8161
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 440 2243.102630 155281.6300 69.2263
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 5840 544652.0000 240974.0500 0.4424
Subtotal (Total Children Is Unduplicated) 15492 699152.4306 3429886.2701 4.9058
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:Program Patients
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
-----------------------------------------------------------------------------------------------------------------------
Total 747713.967565 5032580.0001 6.7306
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 22976
-----------------------------------------------------------------------------------------------------------------------
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 17503 76586.000000 270781.1400 270781.1400
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
5890 4062.500000 115529.9500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 25299 92849.250000 415106.6400 286527.1800
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 4349 11603.750000 104366.3700 104012.7700
1 1.000000 71.4400 51.0500
Other 3210 12991.000000 53852.9600 0.0000
---------------------------------------------------------
Total 7560 24595.750000 158290.7700 104063.8200
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
14084 71742.250000 275432.4500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 14084 71742.250000 275432.4500 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 3655 14729.750000 254531.0100 254319.4100
D 48 75.500000 2793.5000 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
3171 2960.750000 121331.1400 0.0000
Other 5 4.000000 182.4900 60.0000
---------------------------------------------------------
Total 6887 17796.000000 379458.1400 254549.4100
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 5479 66727.500000 169631.7800 169628.6640
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
2603 1653.500000 44122.1900 63.8000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 8082 68381.000000 213753.9700 169692.4640
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
12206 9000.250000 200164.9000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 18949 15607.000000 299403.8600 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 2921 6407.500000 138232.0300 138232.0300
D 210 171.750000 7360.2500 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
6401 4238.250000 130867.5000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 9532 10817.500000 276459.7800 138232.0300
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 13761 120552.000000 570044.9400 570044.9400
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 13803 120643.500000 573157.1600 570044.9400
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
6386 5121.250000 169542.0000 60.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 16325 35717.750000 918719.0900 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 1440 10966.000000 79437.2200 79455.2200
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
2873 2737.500000 71801.3500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 4313 13703.500000 151238.5700 79455.2200
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 6337 59571.750000 169591.9200 166632.3800
3177 1965.000000 49991.7600 174.0100
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 9531 61551.500000 220279.5300 166916.3900
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 4639 32907.000000 55959.7000 55959.7000
T 1714 12107.250000 20592.9100 20592.9100
11674 18264.000000 152986.9800 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 18027 63278.250000 229539.5900 76552.6100
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 6220 41475.070000 78461.7400 78461.7400
T 3348 24165.750000 40950.6400 40518.4100
15744 41351.070000 181766.0400 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 25312 106991.890000 301178.4200 118980.1500
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 7168 12505.881670 147134.7801 147134.7800
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 3064 6120.766431 67027.1800 67027.1800
4796 2943.179464 100106.9600 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 15028 21569.827565 314268.9201 214161.9600
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 3431 19923.750000 202091.4900 202089.6600
2570 2453.750000 100868.5000 255.2500
Other 2 5.000000 50.0000 50.0000
---------------------------------------------------------
Total 6090 22469.000000 306293.1100 204873.3300