CMS/EIP Fiscal Report Statewide
Services beginning 04/01/2018 ending 06/30/2018 Date of Report:08/10/2018 Page: 1
List order: No List
Payclass Filters:GR
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 11654 13555.00000 501369.5000 36.9878
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 8158 8173.000000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 7644 23374.75000 864496.2500 36.9842
Subtotal (Total Children Is Unduplicated) 17799 45102.75000 1365865.7500 30.2834
-----------------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
ASTE-ASTE-ASSISTIVE TECHNOLOGY EVAL 27 29.000000 1406.5000 48.5000
AUDE-92552-PURE TONE AUDIOMETRY -AIR ONLY 86 91.000000 1630.7200 17.9200
AUDE-92553-PURE TONE AUDIOMETRY AIR & BONE 4 4.000000 85.4000 21.3500
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 94 100.000000 1261.0000 12.6100
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 108 114.000000 941.6400 8.2600
AUDE-92568-ACOUSTIC REFLEX TESTING (MEMR) 1 1.000000 9.0600 9.0600
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 123 130.000000 3290.3000 25.3100
AUDE-92585-AUD EVOKED RESPONSE (COMP) 2 2.000000 154.2600 77.1300
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 70 71.000000 1317.0500 18.5500
AUDE-92588-OTOACOUSTIC EMISSIONS (COMP) 21 23.000000 475.6400 20.6800
AUDE-V5010-ASSESSMENT FOR HEARING AID 3 4.000000 180.0000 45.0000
AUDE-V5090-DISPENSING FEE PER HEARING AID 3 5.000000 575.0000 115.0000
BEHV-H2014BA-BEHAVIOR ANALYSIS-ASSOCIATE 2 14.000000 682.6400 48.7600
EVAL-96111-DEVELOPMENTAL EVALUATION 114 125.500000 6275.0000 50.0000
EXIT-EXIT-EXIT ASSESSMENT 854 1430.500000 71362.5000 49.8864
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 31 49.500000 3708.9400 74.9281
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 19 22.500000 1687.5000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 3 5.000000 375.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 21 30.500000 2287.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 52 74.500000 4107.0000 55.1275
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 492 791.701233 58907.5600 74.4063
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 177 268.569834 20118.7900 74.9108
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 147 243.167000 18215.6600 74.9101
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 699 1037.500000 57111.3000 55.0470
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 299 474.500000 35386.1600 74.5757
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 61 61.000000 3266.5500 53.5500
MED-99204-OUTPATIENT VISIT, NEW, 45 MINS 10 10.000000 757.2000 75.7200
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 4 4.000000 106.4400 26.6100
MED-99214-OUTPATIENT VISIT, EST, 25 MINS 1 1.000000 41.4600 41.4600
NUTR-97802-NUTRITIONAL EVAL, INITIAL 1 3.000000 150.0000 50.0000
NUTR-97803-NUTRITIONAL EVAL, FOLLOW-UP 8 18.000000 900.0000 50.0000
OCTF-97168-OT RE-EVAL EST PLAN CARE 18 18.000000 866.1200 48.1178
OCTH-97165-OT EVAL LOW COMPLEXITY 10 10.000000 510.5000 51.0500
OCTH-97166-OT EVAL MODERATE COMPLEXITY 30 31.000000 1582.5500 51.0500
OCTH-97167-OT EVAL HIGH COMPLEXITY 59 59.000000 3011.9500 51.0500
PSTF-97164-PT RE-EVAL EST PLAN CARE 7 6.182200 292.1800 47.2615
PSTH-97161-PT EVAL LOW COMPLEXITY 1 1.000000 51.0500 51.0500
PSTH-97162-PT EVAL MODERATE COMPLEXITY 12 12.000000 612.6000 51.0500
PSTH-97163-PT EVAL HIGH COMPLEXITY 30 30.000000 1487.4600 49.5820
SCREEN-T1023-SCREENING 79 88.000000 4400.0000 50.0000
SPCH-92521-EVAL OF SPEECH FLUENCY 3 3.000000 153.1500 51.0500
SPCH-92522-EVAL OF SPCH SOUND PROD 2 2.000000 102.1000 51.0500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 128 127.000000 6365.2000 50.1197
SPCH-92524-BEHAV & QUAL ANALYSIS OF VOICE AND RES 8 8.000000 408.4000 51.0500
SPCH-92610-EVAL OF ORAL,PHARYNGEAL SWALLOWING FUNC 3 3.000000 133.6500 44.5500
Subtotal (Total Children Is Unduplicated) 2609 5636.620267 316750.6800 56.1951
-----------------------------------------------------------------------------------------------------------------------
EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 30 55.000000 16152.2800 293.6778
AUD-92592TS-AUDIOLOGY SERVICES (Monaural) 1 1.000000 50.0000 50.0000
AUD-92593TS-AUDIOLOGY SERVICES (Biaural) 1 1.000000 25.7400 25.7400
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 1554 1826.500000 90662.5000 49.6373
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 43 28.750000 718.7500 25.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 2301 4561.750000 227925.0000 49.9644
CONIP-CONIP-CONSULT, ITDS PHONE 179 213.000000 5306.2500 24.9120
CONOF-CONOF-CONSULT, OT, FACE TO FACE 500 831.000000 41525.0000 49.9699
CONOP-CONOP-CONSULT, OT, PHONE 37 56.750000 1418.7500 25.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 366 565.250000 28225.0000 49.9337
CONPP-CONPP-CONSULT, PT, PHONE 15 8.250000 206.2500 25.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 1307 1692.500000 84587.5000 49.9778
CONSP-CONSP-CONSULT, SLP, PHONE 83 138.250000 3456.2500 25.0000
COUN-H2019HR-INDIVIDUAL/FAMILY THERAPY 22 47.000000 3446.0400 73.3200
DSTT-DSTT-DIRECT SERVICE COORDINATOR TRAVEL 1961 4771.750000 0.0000 0.0000
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 53 238.750000 5968.7500 25.0000
EIIF-EIIF_NM-EI INDIVIDUAL SESSION BY NONMED PROF 10 64.000000 3200.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 2929 19880.17400 990269.5600 49.8119
INTR-T1013-INTERPRETER 471 1781.000000 83762.8600 47.0314
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 14156 130619.0000 1302838.8600 9.9743
OCCT-97530-OT SESSION BY LICENSED OT 568 2744.626988 191824.4700 69.8909
OCCT-97530HM-OT SESSION BY OT ASST 141 754.445562 43083.7400 57.1065
PHY-97110-PT SESSION BY LICENSED PT 599 3022.869377 208722.2900 69.0477
PHY-97110HM-PT SESSION BY PT ASST 60 420.500524 24035.8100 57.1600
SENS-V5014-*HEARING AID REPAIR BY MANUFACTURER 1 1.000000 50.0000 50.0000
CMS/EIP Fiscal Report Statewide
Services beginning 04/01/2018 ending 06/30/2018 Date of Report:08/10/2018 Page: 2
List order: No List
Payclass Filters:GR
Eligibility Filter:Part C (excluding not eligible)
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
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 3 5.000000 90.0000 18.0000
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 1187 6825.197077 477372.0800 69.9426
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 28 98.000000 5605.6000 57.2000
SPL-92508-GROUP SPL SESSION PER CHILD 20 230.000000 3192.4000 13.8800
TRAV-TRAVS-Travel by mile 6164 577494.0000 255175.9000 0.4419
Subtotal (Total Children Is Unduplicated) 16492 758979.3135 4099581.6300 5.4014
-----------------------------------------------------------------------------------------------------------------------
Total 809718.683795 5782198.0600 7.1410
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 23312
-----------------------------------------------------------------------------------------------------------------------
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 11568 49789.500000 183098.7400 183098.7400
D 398 1836.250000 6682.0600 0.0000
S 3 2.250000 83.2500 0.0000
H 6 6.000000 407.2000 0.0000
T 10726 51022.250000 163636.7300 163684.2900
6358 4148.000000 126681.9100 10.0000
Other 3 3.000000 171.4400 0.0000
---------------------------------------------------------
Total 29062 106807.250000 480761.3300 346793.0300
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 5308 14581.750000 109002.3700 109046.8300
1 1.000000 73.3200 76.2000
Other 3720 15258.750000 60593.7100 0.0000
---------------------------------------------------------
Total 9029 29841.500000 169669.4000 109123.0300
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
21838 108676.250000 454224.2500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 21838 108676.250000 454224.2500 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 4308 17506.750000 310644.8700 310644.8700
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 23 76.000000 3015.6200 491.6000
T 0 0.000000 0.0000 0.0000
3023 2873.000000 115967.2800 0.0000
Other 10 26.000000 1394.3800 857.5100
---------------------------------------------------------
Total 7364 20481.750000 431022.1500 311993.9800
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 5934 77028.000000 193088.9800 191896.5700
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
3264 2307.000000 52348.0000 548.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 9198 79335.000000 245436.9800 192444.5700
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 9339 9249.250000 140977.9800 140977.9800
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
12263 8830.500000 205331.0700 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 21602 18079.750000 346309.0500 140977.9800
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 4295 13639.000000 268886.4500 268886.4500
D 193 143.500000 5713.2500 0.0000
S 11 22.000000 1650.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
7021 4506.000000 133891.5100 196.4600
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 11520 18310.500000 410141.2100 269082.9100
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 14497 85577.250000 543774.3900 543775.0700
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
41 145.000000 2291.7000 0.0000
Other 1 1.500000 83.2500 0.0000
---------------------------------------------------------
Total 14539 85723.750000 546149.3400 543775.0700
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 11252 33773.500000 855315.9600 855315.9600
D 59 37.000000 1315.0000 20.0000
S 1 0.250000 6.2500 6.2500
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
6618 4983.500000 158845.2500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 17930 38794.250000 1015482.4600 855342.2100
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 2969 21644.750000 179562.8300 179562.8300
D 4 3.500000 167.5000 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
2277 1833.000000 64231.2800 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 5250 23481.250000 243961.6100 179562.8300
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 0 0.000000 0.0000 0.0000
D 8 6.750000 337.5000 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 6432 58800.250000 173633.5200 169704.4500
3131 2045.000000 46018.2800 44.0300
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 9571 60852.000000 219989.3000 169748.4800
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 17 15.500000 573.5000 0.0000
H 2611 20286.851483 34345.1100 34345.1100
T 2071 13239.000000 25625.4900 25625.4900
14450 33418.199330 190191.1300 0.0000
Other 4 4.000000 200.0000 0.0000
---------------------------------------------------------
Total 19153 66963.550813 250935.2300 59970.6000
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 176 137.250000 5837.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 4792 27929.340000 59139.9100 59139.9100
T 5171 32135.380000 63677.3900 63677.3900
15832 41907.590000 197920.0400 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 25971 102109.560000 326574.3400 122817.3000
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 11985 20702.950315 260699.3600 260699.3600
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
4482 2490.622667 86151.2000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 16467 23193.572982 346850.5600 260699.3600
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 16 15.750000 639.2500 0.0000
S 27 43.000000 1130.0800 1130.0800
H 0 0.000000 0.0000 0.0000
T 3710 24809.000000 211086.0200 210605.4400
2170 2201.000000 81835.5000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 5923 27068.750000 294690.8500 211735.5200