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
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 11864 13232.50000 489391.7500 36.9841
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 8498 8624.500000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 8171 25917.50000 958227.7500 36.9722
Subtotal (Total Children Is Unduplicated) 18608 47774.50000 1447619.5000 30.3011
-----------------------------------------------------------------------------------------------------------------------
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 58 60.000000 1075.2000 17.9200
AUDE-92553-PURE TONE AUDIOMETRY AIR & BONE 3 3.000000 64.0500 21.3500
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 63 65.000000 819.6500 12.6100
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 67 72.000000 594.7200 8.2600
AUDE-92568-ACOUSTIC REFLEX TESTING (MEMR) 1 1.000000 9.0600 9.0600
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 102 104.000000 2632.2400 25.3100
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 61 61.000000 1131.5500 18.5500
AUDE-92588-OTOACOUSTIC EMISSIONS (COMP) 11 11.000000 227.4800 20.6800
AUDE-V5010-ASSESSMENT FOR HEARING AID 1 1.000000 45.0000 45.0000
AUDE-V5090-DISPENSING FEE PER HEARING AID 2 3.000000 345.0000 115.0000
EVAL-96111-DEVELOPMENTAL EVALUATION 88 110.500000 5530.5000 50.0498
EXIT-EXIT-EXIT ASSESSMENT 881 1416.000000 70775.0000 49.9823
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 52 76.000000 5640.0000 74.2105
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 23 24.000000 1800.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 11 16.500000 1237.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 29 39.500000 2962.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 68 91.000000 5050.5000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 647 912.151432 68023.4200 74.5747
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 215 306.221600 22966.6300 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 194 297.611900 22320.8900 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 962 1275.980000 70670.9800 55.3856
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 375 510.500000 38107.6900 74.6478
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 66 66.000000 3534.3000 53.5500
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 9 9.000000 239.4900 26.6100
NUTR-97802-NUTRITIONAL EVAL, INITIAL 1 5.000000 250.0000 50.0000
NUTR-97803-NUTRITIONAL EVAL, FOLLOW-UP 15 81.000000 4050.0000 50.0000
OCTF-97168-OT RE-EVAL EST PLAN CARE 23 23.000000 1174.1500 51.0500
OCTH-97166-OT EVAL MODERATE COMPLEXITY 39 40.500000 1953.0700 48.2240
OCTH-97167-OT EVAL HIGH COMPLEXITY 74 72.811558 3717.0300 51.0500
PSTF-97164-PT RE-EVAL EST PLAN CARE 12 12.000000 586.2600 48.8550
PSTH-97162-PT EVAL MODERATE COMPLEXITY 14 14.000000 714.7000 51.0500
PSTH-97163-PT EVAL HIGH COMPLEXITY 22 22.000000 1123.1000 51.0500
SCREEN-T1023-SCREENING 20 31.000000 1550.0000 50.0000
SPCH-92521-EVAL OF SPEECH FLUENCY 1 1.000000 51.0500 51.0500
SPCH-92522-EVAL OF SPCH SOUND PROD 2 2.000000 57.1000 28.5500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 127 127.000000 6448.3500 50.7744
SPCH-92524-BEHAV & QUAL ANALYSIS OF
VOICE AND RES 12 12.000000 612.6000 51.0500
Subtotal (Total Children Is Unduplicated) 2877 5998.276490 349206.2600 58.2178
-----------------------------------------------------------------------------------------------------------------------
EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 35 65.000000 22125.9400 340.3991
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 1426 1724.000000 85697.0000 49.7082
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 70 54.000000 1350.0000 25.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 2195 4195.750000 209568.7500 49.9479
CONIP-CONIP-CONSULT, ITDS PHONE 199 222.750000 5568.7500 25.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 451 785.250000 39218.7500 49.9443
CONOP-CONOP-CONSULT, OT, PHONE 32 37.500000 937.5000 25.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 360 470.000000 23487.5000 49.9734
CONPP-CONPP-CONSULT, PT, PHONE 10 6.250000 156.2500 25.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 1292 1605.250000 80262.5000 50.0000
CONSP-CONSP-CONSULT, SLP, PHONE 97 159.750000 3993.7500 25.0000
COUN-H2019HR-INDIVIDUAL/FAMILY THERAPY 5 8.000000 586.5600 73.3200
DSTT-DSTT-DIRECT SERVICE COORDINATOR TRAVEL 1982 4399.000000 0.0000 0.0000
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 48 192.000000 4800.0000 25.0000
EIIF-EIIF_NM-EI INDIVIDUAL SESSION BY NONMED PROF 10 59.000000 2950.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 2738 18064.18140 900092.1100 49.8275
INTR-T1013-INTERPRETER 540 2114.000000 96884.1800 45.8298
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 13386 115745.0000 1153276.4600 9.9639
OCCT-97530-OT SESSION BY LICENSED OT 510 2547.130268 180164.7400 70.7324
OCCT-97530HM-OT SESSION BY OT ASST 114 679.589900 38872.2100 57.1995
PHY-97110-PT SESSION BY LICENSED PT 499 2687.783810 188763.7100 70.2302
PHY-97110HM-PT SESSION BY PT ASST 45 326.626310 18669.9600 57.1600
SENS-V5014-*HEARING AID REPAIR BY MANUFACTURER 1 2.000000 228.0000 114.0000
SENS-V5050-IN EAR MONAURAL HEARING AID 1 2.000000 456.0000 228.0000
SENS-V5060-BEHIND EAR HEARING AID
1 1.000000 228.0000 228.0000
SENS-V5264-EARMOLD 4 7.000000 126.0000 18.0000
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 1104 6659.532855 472246.7900 70.9129
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 3 22.000000 1258.4000 57.2000
SPL-92508-GROUP SPL SESSION PER CHILD 2 5.000000 69.4000 13.8800
TRAV-TRAVS-Travel by mile 5972 576202.0000 254906.8500 0.4424
Subtotal (Total Children Is Unduplicated) 15961 739048.3445 3786946.0600 5.1241
-----------------------------------------------------------------------------------------------------------------------
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
Payclass Filters:GR
Eligibility Filter:Program Patients
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Total 792821.121033 5583771.8200 7.0429
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 23555
-----------------------------------------------------------------------------------------------------------------------
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 17394 76200.250000 281362.4800 281362.4800
D 497 2290.750000 7505.3600 0.0000
S 2 1.000000 37.0000 0.0000
H 4 4.500000 326.8200 0.0000
T 1341 7635.000000 17362.9400 17365.6400
6290 4230.000000 131199.5000 0.0000
Other 1 2.000000 150.0000 0.0000
---------------------------------------------------------
Total 25529 90363.500000 437944.1000 298728.1200
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 4265 10429.000000 89774.1800 89506.2090
133 685.250000 4415.1100 0.0000
Other 3611 15555.750000 60649.1000 0.0000
---------------------------------------------------------
Total 8009 26670.000000 154838.3900 89506.2090
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
20484 102518.750000 440488.0800 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 20484 102518.750000 440488.0800 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 3383 13449.750000 239165.8600 239165.8600
D 8 5.750000 212.7500 0.0000
S 0 0.000000 0.0000 0.0000
H 19 81.000000 3130.0100 350.0000
T 0 0.000000 0.0000 0.0000
3894 3873.750000 157602.8400 0.0000
Other 9 23.500000 1345.7300 180.0000
---------------------------------------------------------
Total 7313 17433.750000 401457.1900 239695.8600
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 4018 49817.250000 127811.6500 127640.7100
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
2923 1965.750000 48488.9400 129.9400
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 6941 51783.000000 176300.5900 127770.6500
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 7924 7785.750000 115700.5900 115700.5900
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
12712 9129.500000 209209.0800 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 20636 16915.250000 324909.6700 115700.5900
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 2542 7231.500000 140699.7500 140699.7500
D 241 184.000000 7108.0000 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
6647 4176.000000 126306.2500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 9430 11591.500000 274114.0000 140699.7500
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 15413 133658.500000 658241.1900 658241.1900
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
287 5089.000000 15652.1800 0.0000
Other 5 9.000000 567.7500 0.0000
---------------------------------------------------------
Total 15705 138756.500000 674461.1200 658241.1900
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 10567 31216.000000 783134.4000 783134.4000
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
7754 6106.500000 196860.5000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 18410 37379.250000 982094.6500 783134.4000
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 2897 17202.000000 179116.4200 179116.4200
D 1 0.250000 9.2500 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
4214 2701.750000 91190.6300 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 7112 19904.000000 270316.3000 179116.4200
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 7 55.250000 244.7500 244.7500
D 3 2.500000 125.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 6114 57802.750000 163628.2100 160291.5100
3172 1961.250000 47855.5200 54.2700
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 9296 59821.750000 211853.4800 160590.5300
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 3965 29257.500000 47060.7000 47060.7000
T 2070 15712.250000 27144.5800 27144.5800
11373 10757.371400 146640.8100 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 17408 55727.121400 220846.0900 74205.2800
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 36 27.250000 1072.7500 0.0000
S 0 0.000000 0.0000 0.0000
H 5098 34384.750000 67270.2900 67270.2900
T 5187 34812.350000 64422.6300 64422.6300
16553 42628.190000 212578.4300 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 26874 111852.540000 345344.1000 131692.9200
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 11186 19834.420701 235365.7400 235365.7400
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
4501 2748.788932 91859.7200 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 15687 22583.209633 327225.4600 235365.7400
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 0 0.000000 0.0000 0.0000
D 10 12.500000 519.0000 0.0000
S 153 102.500000 6061.9800 6061.9800
H 0 0.000000 0.0000 0.0000
T 3829 26736.250000 225326.1700 225426.1700
2658 2666.750000 109518.5700 214.3200
Other 5 3.000000 152.8800 152.8800
---------------------------------------------------------
Total 6655 29521.000000 341578.6000 231855.3500