CMS/EIP Fiscal Report Statewide
Services beginning 01/01/2018 ending 03/31/2018 Date of Report:05/05/2018 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 11867 13239.25000 489641.5000 36.9841
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 8498 8626.000000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 23170 73472.00000 2717234.2500 36.9833
Subtotal (Total Children Is Unduplicated) 24195 95337.25000 3206875.7500 33.6372
-----------------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
ASTE-ASTE-ASSISTIVE TECHNOLOGY EVAL 22 23.000000 1115.5000 48.5000
AUDE-92552-PURE TONE AUDIOMETRY -AIR ONLY 76 78.000000 1397.7600 17.9200
AUDE-92553-PURE TONE AUDIOMETRY AIR & BONE 3 3.000000 64.0500 21.3500
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 81 83.000000 1046.6300 12.6100
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 88 94.000000 769.9400 8.1909
AUDE-92568-ACOUSTIC REFLEX TESTING (MEMR) 3 3.000000 27.1800 9.0600
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 125 127.000000 3214.3700 25.3100
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 67 67.000000 1242.8500 18.5500
AUDE-92588-OTOACOUSTIC EMISSIONS (COMP) 12 12.000000 248.1600 20.6800
AUDE-V5010-ASSESSMENT FOR HEARING AID 2 2.000000 90.0000 45.0000
AUDE-V5090-DISPENSING FEE PER HEARING AID 3 5.000000 575.0000 115.0000
EVAL-96111-DEVELOPMENTAL EVALUATION 91 123.500000 6180.5000 50.0445
EXIT-EXIT-EXIT ASSESSMENT 899 1446.000000 72275.0000 49.9827
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 201 350.500000 26115.0000 74.5078
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 93 145.500000 10837.5000 74.4845
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 41 69.000000 5175.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 128 203.500000 15856.7100 77.9200
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 235 400.000000 22085.0000 55.2125
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 2798 4456.500000 331352.9900 74.3527
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 1119 1785.000000 133408.6100 74.7387
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 858 1364.500000 102026.2900 74.7719
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 3236 5094.500000 281503.2900 55.2563
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 1598 2422.000000 183650.2400 75.8259
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 145 146.000000 13212.2500 90.4949
MED-99204-OUTPATIENT VISIT, NEW, 45 MINS 1 1.000000 507.0000 507.0000
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 21 21.000000 1114.0300 53.0490
NUTR-97802-NUTRITIONAL EVAL, INITIAL 1 5.000000 250.0000 50.0000
NUTR-97803-NUTRITIONAL EVAL, FOLLOW-UP 18 90.000000 4500.0000 50.0000
OCTF-97168-OT RE-EVAL EST PLAN CARE 41 40.770029 2081.3100 51.0500
OCTH-97165-OT EVAL LOW COMPLEXITY 2 2.000000 62.1000 31.0500
OCTH-97166-OT EVAL MODERATE COMPLEXITY 77 79.500000 3932.9700 49.4713
OCTH-97167-OT EVAL HIGH COMPLEXITY 171 178.229971 9058.6400 50.8256
PSTF-97164-PT RE-EVAL EST PLAN CARE 26 26.000000 1300.9600 50.0369
PSTH-97161-PT EVAL LOW COMPLEXITY 2 2.000000 102.1000 51.0500
PSTH-97162-PT EVAL MODERATE COMPLEXITY 26 27.000000 1426.2500 52.8241
PSTH-97163-PT EVAL HIGH COMPLEXITY 113 113.000000 5753.6500 50.9173
SCREEN-T1023-SCREENING 58 73.000000 3650.0000 50.0000
SPCH-92521-EVAL OF SPEECH FLUENCY 3 3.000000 153.1500 51.0500
SPCH-92522-EVAL OF SPCH SOUND PROD 4 4.000000 159.2000 39.8000
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 293 297.000000 15050.8000 50.6761
SPCH-92524-BEHAV & QUAL ANALYSIS OF
VOICE AND RES 24 24.000000 1225.2000 51.0500
SPCH-92610-EVAL OF ORAL,PHARYNGEAL SWALLOWING FUNC 2 2.000000 89.1000 44.5500
Subtotal (Total Children Is Unduplicated) 6813 19492.00000 1263886.2800 64.8413
-----------------------------------------------------------------------------------------------------------------------
EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 45 114.000000 33105.2800 290.3972
AUD-92592TS-AUDIOLOGY SERVICES (Monaural) 1 1.000000 50.0000 50.0000
AUD-92593TS-AUDIOLOGY SERVICES (Biaural) 1 1.000000 50.0000 50.0000
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 1441 1757.000000 87347.0000 49.7137
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 71 55.000000 1375.0000 25.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 2201 4207.500000 210156.2500 49.9480
CONIP-CONIP-CONSULT, ITDS PHONE 199 222.750000 5568.7500 25.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 456 790.250000 39468.7500 49.9446
CONOP-CONOP-CONSULT, OT, PHONE 32 37.500000 937.5000 25.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 367 480.500000 24012.5000 49.9740
CONPP-CONPP-CONSULT, PT, PHONE 10 6.250000 156.2500 25.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 1298 1615.250000 80762.5000 50.0000
CONSP-CONSP-CONSULT, SLP, PHONE 97 159.750000 3993.7500 25.0000
COUN-H2019HR-INDIVIDUAL/FAMILY THERAPY 6 15.000000 1099.8000 73.3200
DSTT-DSTT-DIRECT SERVICE COORDINATOR TRAVEL 1997 4449.250000 0.0000 0.0000
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 131 6052.000000 151300.0000 25.0000
EIIF-96154-HEALTH AND BEHAVIOR INTERVENTION 1 42.000000 2100.0000 50.0000
EIIF-EIIF_NM-EI INDIVIDUAL SESSION BY NONMED PROF 10 60.000000 3000.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 8946 67493.00000 3369869.5200 49.9292
INTR-T1013-INTERPRETER 540 2115.000000 96934.1800 45.8318
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 13393 115860.0000 1154426.4600 9.9640
OCCT-97530-OT SESSION BY LICENSED OT 1195 6406.250603 450313.4603 70.2928
OCCT-97530HM-OT SESSION BY OT ASST 435 2803.438000 160202.4200 57.1450
PHY-97110-PT SESSION BY LICENSED PT 1145 6696.500200 468966.7200 70.0316
PHY-97110HM-PT SESSION BY PT ASST 242 1638.000000 93628.0800 57.1600
SENS-V5014-*HEARING AID REPAIR BY MANUFACTURER 1 2.000000 228.0000 114.0000
SENS-V5050-IN EAR MONAURAL HEARING AID 2 4.000000 912.0000 228.0000
SENS-V5060-BEHIND EAR HEARING AID
1 1.000000 228.0000 228.0000
CMS/EIP Fiscal Report Statewide
Services beginning 01/01/2018 ending 03/31/2018 Date of Report:05/05/2018 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 10 18.000000 324.0000 18.0000
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 2620 17048.86670 1199613.0300 70.3632
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 107 417.000000 23852.4000 57.2000
SPL-92508-GROUP SPL SESSION PER CHILD 14 39.500000 548.2600 13.8800
TRAV-TRAVS-Travel by mile 6015 591858.0000 261842.0100 0.4424
Subtotal (Total Children Is Unduplicated) 16595 832466.5555 7926371.8703 9.5216
-----------------------------------------------------------------------------------------------------------------------
Total 947295.805503 12397133.9003 13.0869
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 26176
-----------------------------------------------------------------------------------------------------------------------
Center 01
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 8338 5603.250000 221327.2900 0.0000
P 19655 78542.250000 417022.4300 417022.4300
D 868 2672.750000 30271.1300 0.0000
S 138 134.250000 7695.9300 0.0000
H 418 465.750000 32028.8600 0.0000
T 1437 7730.750000 22940.1000 22362.4100
6428 4357.750000 138206.7000 0.0000
Other 292 385.000000 23669.2000 0.0000
---------------------------------------------------------
Total 37574 99891.750000 893161.6400 439384.8400
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 4673 10807.750000 115523.9000 114837.7190
180 730.750000 7533.3000 0.0000
Other 5488 16973.000000 122748.8500 0.0000
---------------------------------------------------------
Total 10341 28511.500000 245806.0500 114837.7190
Center 03
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 36 25.000000 981.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 3251 2309.250000 96927.6900 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
20533 102557.750000 442499.3700 0.0000
Other 2 0.500000 18.5000 0.0000
---------------------------------------------------------
Total 23822 104892.500000 540427.0600 0.0000
Center 04
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 17 15.000000 555.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 303 459.750000 17158.8000 0.0000
P 6753 18733.000000 453164.7100 453300.2350
D 8 5.750000 212.7500 0.0000
S 1 1.500000 55.5000 0.0000
H 2306 9523.500000 487610.6400 350.0000
T 0 0.000000 0.0000 0.0000
4782 10268.000000 364087.4300 0.0000
Other 96 239.000000 15654.8700 322.9000
---------------------------------------------------------
Total 14266 39245.500000 1338499.7000 453973.1350
Center 05
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 3 2.500000 92.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 2863 1884.250000 75622.5000 0.0000
P 4170 50057.750000 144377.2400 144207.0200
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
2925 1966.750000 48525.9400 129.9400
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 9961 53911.250000 268618.1800 144336.9600
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 10027 9559.000000 214099.7000 214099.7000
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
19917 14836.000000 480465.8000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 29944 24395.000000 694565.5000 214099.7000
Center 07
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 2 2.250000 159.2500 0.0000
U 0 0.000000 0.0000 0.0000
B 35 30.500000 1489.5000 0.0000
P 7812 11430.500000 318599.7100 318599.7100
D 242 184.250000 7117.2500 0.0000
S 3 2.750000 177.7500 0.0000
H 1 2.250000 83.2500 0.0000
T 0 0.000000 0.0000 0.0000
6671 4206.500000 127580.8900 0.0000
Other 1 1.000000 37.0000 0.0000
---------------------------------------------------------
Total 14767 15860.000000 455244.6000 318599.7100
Center 09
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 28 29.750000 1150.9500 50.0000
P 20652 154733.000000 943782.2500 944763.3520
D 13 18.500000 1327.1400 0.0000
S 0 0.000000 0.0000 0.0000
H 61 111.500000 7603.3800 0.0000
T 0 0.000000 0.0000 0.0000
3111 13054.250000 438317.1600 74.4000
Other 271 430.000000 31489.5000 0.0000
---------------------------------------------------------
Total 24136 168377.000000 1423670.3800 944887.7520
Center 10
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 8 3.250000 120.2500 0.0000
U 0 0.000000 0.0000 0.0000
B 10938 8742.000000 365211.0000 0.0000
P 10896 31738.500000 815146.6800 814975.2000
D 89 56.750000 2099.7500 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
11728 19182.250000 889500.4000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 33659 59722.750000 2072078.0800 814975.2000
Center 51
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 4 1.500000 62.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 2081 1237.250000 47647.2500 0.0000
P 3616 19505.000000 332587.0100 332495.2100
D 14 6.500000 240.5000 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
5427 6071.000000 294969.9900 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 11142 26821.250000 675506.7500 332495.2100
Center 52
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 24 18.750000 707.0000 150.0000
P 3309 3129.000000 145195.5400 142575.8300
D 73 83.500000 4679.6200 0.0000
S 22 40.500000 2827.5000 0.0000
H 80 102.250000 6766.8900 0.0000
T 6897 59046.000000 239874.5000 228569.4200
4326 4286.750000 184099.1700 54.2700
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 14731 66706.750000 584150.2200 371349.5200
Center 53
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 2 2.000000 74.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 348 233.000000 8621.0000 0.0000
P 3377 3259.978600 147984.6800 145597.7800
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 4037 29329.750000 51598.8000 51598.8000
T 2099 15743.750000 28860.6200 28860.6200
13904 13448.521400 286899.9900 0.0000
Other 65 70.750000 3799.2500 0.0000
---------------------------------------------------------
Total 23832 62087.750000 527838.3400 226057.2000
Center 54
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 62 61.250000 2507.2500 0.0000
U 0 0.000000 0.0000 0.0000
B 4107 3115.750000 128218.0000 0.0000
P 1039 989.750000 48532.7500 48505.0000
D 38 28.500000 1132.0000 0.0000
S 229 258.500000 15056.5000 15047.2500
H 5282 34564.750000 75570.2300 75220.2300
T 5265 34897.350000 69258.9800 69258.9800
21608 47844.150000 479684.1700 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 37630 121760.000000 819959.8800 208031.4600
Center 55
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 6 7.750000 286.7500 0.0000
P 16279 24395.082627 455117.9000 455040.9000
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 0 0.000000 0.0000 0.0000
9653 7620.972876 395689.0503 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 25939 32025.805503 851243.7003 455040.9000
Center 57
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 2961 3190.500000 126499.7500 0.0000
P 137 90.396700 5853.7800 5853.7800
D 10 12.500000 519.0000 0.0000
S 248 152.500000 9486.3200 9486.3200
H 4 3.000000 166.5000 0.0000
T 4375 28471.103300 315620.0200 315412.8200
5521 10883.750000 544886.6500 435351.2800
Other 70 283.250000 3331.8000 3331.8000
---------------------------------------------------------
Total 13326 43087.000000 1006363.8200 769436.0000