CMS/EIP Fiscal Report Statewide
Services beginning 10/01/2018 ending 12/31/2018 Date of Report:02/06/2019 Page: 1
List order: No List
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 11901 13120.50000 485319.7500 36.9894
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 6855 6616.750000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 21535 61272.50000 2264702.5000 36.9612
Subtotal (Total Children Is Unduplicated) 22861 81009.75000 2750022.2500 33.9468
-----------------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
ASTE-ASTE-ASSISTIVE TECHNOLOGY EVAL 26 26.000000 1261.0000 48.5000
AUDE-92552-PURE TONE AUDIOMETRY -AIR ONLY 57 58.000000 1143.1800 19.7100
AUDE-92553-PURE TONE AUDIOMETRY AIR & BONE 1 1.000000 23.4900 23.4900
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 66 69.000000 943.1600 13.6690
AUDE-92557-COMP AUDIO THRESHOLD EVAL/SPCH RECOG 1 3.000000 51.5500 17.1833
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 72 74.000000 662.8400 8.9573
AUDE-92568-ACOUSTIC REFLEX TESTING (MEMR) 2 2.000000 19.9200 9.9600
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 68 70.000000 1921.5700 27.4510
AUDE-92585-AUD EVOKED RESPONSE (COMP) 1 1.000000 84.8400 84.8400
AUDE-92586-AUD EVOKED RESPONSE (LIMITED) 1 2.000000 59.0600 29.5300
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 25 25.000000 417.5000 16.7000
AUDE-92588-OTOACOUSTIC EMISSIONS (COMP) 13 13.000000 291.2000 22.4000
AUDE-V5010-ASSESSMENT FOR HEARING AID 2 2.000000 90.0000 45.0000
AUDE-V5090-DISPENSING FEE PER HEARING AID 1 1.000000 115.0000 115.0000
BEHV-H2014BA-BEHAVIOR ANALYSIS-ASSOCIATE 3 19.000000 918.2000 48.3263
EVAL-96111-DEVELOPMENTAL EVALUATION 85 105.750000 5287.5000 50.0000
EXIT-EXIT-EXIT ASSESSMENT 885 1447.000000 72197.5000 49.8946
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 156 265.000000 19686.4600 74.2885
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 84 142.000000 10650.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 28 50.000000 3750.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 78 136.500000 10443.9400 76.5124
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 181 315.000000 17460.3000 55.4295
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 2291 3817.500000 283043.9100 74.1438
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 1020 1669.000000 124712.9500 74.7232
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 472 817.000000 60993.4800 74.6554
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 2864 4752.500000 262131.9700 55.1566
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 1327 2227.500000 167545.4600 75.2168
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 76 76.000000 7348.6900 96.6933
MED-99204-OUTPATIENT VISIT, NEW, 45 MINS 12 12.000000 2003.5400 166.9617
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 16 16.000000 439.8500 27.4906
MED-99214-OUTPATIENT VISIT, EST, 25 MINS 1 1.000000 36.4900 36.4900
NUTR-97802-NUTRITIONAL EVAL, INITIAL 2 19.000000 950.0000 50.0000
NUTR-97803-NUTRITIONAL EVAL, FOLLOW-UP 7 45.000000 2250.0000 50.0000
OCTF-97168-OT RE-EVAL EST PLAN CARE 31 31.000000 1582.5500 51.0500
OCTH-97165-OT EVAL LOW COMPLEXITY 16 16.000000 756.7700 47.2981
OCTH-97166-OT EVAL MODERATE COMPLEXITY 48 47.000000 2399.3500 51.0500
OCTH-97167-OT EVAL HIGH COMPLEXITY 103 104.000000 5259.2000 50.5692
PSTF-97164-PT RE-EVAL EST PLAN CARE 14 14.000000 642.4400 45.8886
PSTH-97161-PT EVAL LOW COMPLEXITY 4 5.000000 211.3500 42.2700
PSTH-97162-PT EVAL MODERATE COMPLEXITY 15 15.000000 765.7500 51.0500
PSTH-97163-PT EVAL HIGH COMPLEXITY 91 91.000000 4543.1600 49.9248
SCREEN-T1023-SCREENING 79 85.000000 4250.0000 50.0000
SPCH-92521-EVAL OF SPEECH FLUENCY 3 3.000000 153.1500 51.0500
SPCH-92522-EVAL OF SPCH SOUND PROD 5 5.000000 255.2500 51.0500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 170 169.979432 8567.4300 50.4027
SPCH-92524-BEHAV & QUAL ANALYSIS OF VOICE AND RES 27 26.020568 1283.3500 49.3206
SPCH-92610-EVAL OF ORAL,PHARYNGEAL SWALLOWING FUNC 5 5.000000 244.7000 48.9400
Subtotal (Total Children Is Unduplicated) 5738 16896.75000 1089849.0000 64.5005
-----------------------------------------------------------------------------------------------------------------------
EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 44 96.000000 26176.3200 272.6700
AUD-92592TS-AUDIOLOGY SERVICES (Monaural) 1 1.000000 50.0000 50.0000
AUD-92593TS-AUDIOLOGY SERVICES (Biaural) 4 4.000000 185.4900 46.3725
AUDE-V5160-DISPENSING FEE BINAURAL 2 3.000000 287.0300 95.6767
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 1345 1688.250000 83850.0000 49.6668
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 107 95.250000 2381.2500 25.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 1953 3287.750000 164312.5000 49.9772
CONIP-CONIP-CONSULT, ITDS PHONE 229 206.250000 5150.2500 24.9709
CONOF-CONOF-CONSULT, OT, FACE TO FACE 660 963.000000 48125.0000 49.9740
CONOP-CONOP-CONSULT, OT, PHONE 83 75.750000 1893.7500 25.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 540 713.000000 35612.5000 49.9474
CONPP-CONPP-CONSULT, PT, PHONE 14 12.000000 300.0000 25.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 1294 1692.250000 84375.0000 49.8597
CONSP-CONSP-CONSULT, SLP, PHONE 136 117.000000 2925.0000 25.0000
COUN-H2019HR-INDIVIDUAL/FAMILY THERAPY 16 39.000000 2859.4800 73.3200
DSTT-DSTT-DIRECT SERVICE COORDINATOR TRAVEL 2106 4801.000000 0.0000 0.0000
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 125 5893.750000 147343.7500 25.0000
EIIF-96154-HEALTH AND BEHAVIOR INTERVENTION 3 75.000000 3750.0000 50.0000
EIIF-EIIF_NM-EI INDIVIDUAL SESSION BY NONMED PROF 10 35.000000 1750.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 10567 78615.25000 3914714.7700 49.7959
INTR-T1013-INTERPRETER 292 1594.750000 69501.9000 43.5817
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 13319 112593.0000 1122324.5900 9.9680
OCCT-97530-OT SESSION BY LICENSED OT 1253 6675.749992 466947.5292 69.9468
CMS/EIP Fiscal Report Statewide
Services beginning 10/01/2018 ending 12/31/2018 Date of Report:02/06/2019 Page: 2
List order: No List
Eligibility Filter:Part C (excluding not eligible)
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
OCCT-97530HM-OT SESSION BY OT ASST 436 2606.550699 148773.0200 57.0766
PHY-97110-PT SESSION BY LICENSED PT 1233 7313.718100 509037.6400 69.6004
PHY-97110HM-PT SESSION BY PT ASST 187 1031.751800 58967.6800 57.1530
SENS-V5014-*HEARING AID REPAIR BY MANUFACTURER 1 1.000000 114.0000 114.0000
SENS-V5140-BEHIND EAR BINAURAL HEARING AID 1 1.000000 456.0000 456.0000
SENS-V5264-EARMOLD 5 9.000000 162.0000 18.0000
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 2605 16429.97350 1140411.7293 69.4104
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 5 36.000000 2059.2000 57.2000
SPL-92508-GROUP SPL SESSION PER CHILD 12 27.699900 424.7600 15.3344
TRAV-TRAVS-Travel by mile 6105 558392.0000 246607.3300 0.4416
Subtotal (Total Children Is Unduplicated) 17099 805125.6940 8291829.4685 10.2988
-----------------------------------------------------------------------------------------------------------------------
Total 903032.193993 12131700.7185 13.4344
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 25798
-----------------------------------------------------------------------------------------------------------------------
Center 01
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 600 432.250000 17890.0900 0.0000
U 0 0.000000 0.0000 0.0000
B 701 770.000000 46457.8700 0.0000
P 27748 93817.500000 560509.6400 557674.0900
D 531 1546.500000 13904.6600 0.0000
S 192 496.000000 7793.4500 0.0000
H 152 192.500000 13903.4100 37.0000
T 1403 5061.500000 28552.8300 28465.4200
4243 2920.250000 80504.0800 0.0000
Other 417 549.500000 33235.9700 450.0000
---------------------------------------------------------
Total 35987 105786.000000 802752.0000 586626.5100
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 4 4.000000 40.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 5672 15150.250000 140812.5700 138973.7400
341 1036.500000 6041.9000 0.0000
Other 4547 16638.750000 102797.0700 0.0000
---------------------------------------------------------
Total 10564 32829.500000 249691.5400 138973.7400
Center 03
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 92 67.500000 3069.2500 0.0000
U 0 0.000000 0.0000 0.0000
B 2657 1902.250000 82527.0000 0.0000
P 5605 55148.500000 149495.1700 149495.1700
D 0 0.000000 0.0000 0.0000
S 2 1.750000 64.7500 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
9107 40108.250000 221593.9500 0.0000
Other 1 0.500000 18.5000 0.0000
---------------------------------------------------------
Total 17464 97228.750000 456768.6200 149495.1700
Center 04
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 8 8.500000 314.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 1146 1666.000000 64344.7500 0.0000
P 6531 19374.500000 438043.5500 431983.1700
D 28 37.500000 1387.5000 0.0000
S 0 0.000000 0.0000 0.0000
H 2572 10922.000000 554677.3900 834.6400
T 0 0.000000 0.0000 0.0000
4779 10238.250000 348003.6300 0.0000
Other 78 212.000000 14061.4700 347.1600
---------------------------------------------------------
Total 15142 42458.750000 1420832.7900 433164.9700
Center 05
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 65 46.250000 1711.2500 0.0000
U 0 0.000000 0.0000 0.0000
B 2137 1412.750000 55546.5000 0.0000
P 1809 20740.500000 57746.4100 57746.4100
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
2431 1418.500000 41643.5000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 6442 23618.000000 156647.6600 57746.4100
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 11016 10457.250000 234818.0100 234818.0100
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
26750 21216.500000 806176.3700 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 37766 31673.750000 1040994.3800 234818.0100
Center 07
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 13 9.500000 351.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 40 36.000000 1421.0000 0.0000
P 6381 12627.250000 334603.7500 334289.0000
D 179 143.250000 5982.2500 0.0000
S 9 68.000000 2620.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
6538 4202.250000 128919.0000 0.0000
Other 2 1.000000 37.0000 0.0000
---------------------------------------------------------
Total 13162 17087.250000 473934.5000 334289.0000
Center 09
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 189 222.750000 8241.7500 0.0000
U 0 0.000000 0.0000 0.0000
B 1701 1600.750000 62626.5000 124.5000
P 21682 169142.250000 1003762.2800 1003774.1700
D 11 11.000000 785.8400 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
3488 22881.000000 510228.3100 0.0000
Other 183 309.000000 22630.0000 0.0000
---------------------------------------------------------
Total 27254 194166.750000 1608274.6800 1003898.6700
Center 10
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 384 297.750000 11016.7500 0.0000
U 0 0.000000 0.0000 0.0000
B 5036 4589.250000 201863.2500 0.0000
P 10826 31909.000000 814085.3600 814085.3600
D 62 47.250000 1673.5000 0.0000
S 227 421.000000 16535.3200 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
9408 19193.000000 988296.5500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 25943 56457.250000 2033470.7300 814085.3600
Center 51
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 226 164.000000 5966.2500 0.0000
U 0 0.000000 0.0000 0.0000
B 571 392.500000 15111.0000 0.0000
P 2086 11077.500000 182268.1800 182268.1800
D 1 0.750000 27.7500 0.0000
S 0 0.000000 0.0000 0.0000
H 1 0.250000 9.2500 0.0000
T 0 0.000000 0.0000 0.0000
2633 3382.750000 169349.3000 50.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 5518 15017.750000 372731.7300 182318.1800
Center 52
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 7 3.500000 142.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 1012 990.250000 48275.2500 83.2500
P 2331 2208.500000 99615.9200 97284.7400
D 40 56.500000 3133.0900 150.0000
S 6 7.000000 259.0000 0.0000
H 161 233.500000 15771.3900 0.0000
T 6695 55679.000000 233559.3800 223200.5700
4104 3828.250000 174691.2000 268.7300
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 14356 63006.500000 575447.7300 320987.2900
Center 53
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 21 18.500000 739.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 773 715.500000 29755.7500 2.0000
P 2700 2714.320600 127242.2800 127349.4200
D 1 1.000000 73.3200 0.0000
S 17 17.750000 720.5000 0.0000
H 2254 15655.287512 28278.1100 28278.1100
T 3440 28802.500000 40652.7700 40652.7700
14489 15823.141880 291592.8192 0.0000
Other 201 228.500000 12725.9700 0.0000
---------------------------------------------------------
Total 23896 63976.499992 531781.0192 196282.3000
Center 54
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 3 3.000000 150.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 1618 1251.500000 49967.0000 0.0000
P 3685 3188.650000 141403.9000 159786.4000
D 211 181.750000 8091.0700 0.0000
S 0 0.000000 0.0000 0.0000
H 4984 28149.110000 64737.3500 64737.3500
T 2387 14483.250000 31092.8200 31092.8200
19488 37430.240000 385766.8600 0.0000
Other 30 30.000000 1527.2500 0.0000
---------------------------------------------------------
Total 32406 84717.500000 682736.2500 255616.5700
Center 55
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 2 0.500000 18.5000 0.0000
P 12577 20014.133809 342879.5099 342879.5100
D 0 0.000000 0.0000 0.0000
S 5 3.500000 168.5000 0.0000
H 19 38.000000 2850.0000 0.0000
T 0 0.000000 0.0000 0.0000
13674 14411.310192 499935.5194 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 26277 34467.444001 845852.0293 342879.5100
Center 57
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 1 0.500000 18.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 2167 2631.500000 98693.2500 0.0000
P 341 346.250000 21308.0800 21118.8800
D 0 0.000000 0.0000 0.0000
S 48 85.500000 2861.1700 2861.1700
H 0 0.000000 0.0000 0.0000
T 4269 27229.000000 288400.8800 288399.1600
5964 10126.750000 464528.5400 295405.9000
Other 52 121.000000 3974.6400 3974.6400
---------------------------------------------------------
Total 12842 40540.500000 879785.0600 611759.7500