CMS/EIP Fiscal Report Statewide
Services beginning 10/01/2011 ending 12/31/2011 Date of Report:02/16/2012 Page: 1
List order: No List
Payclass Filters:TPIN
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 4 1.750000 64.7500 37.0000
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 1 1.000000 0.0000 0.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 4 4.250000 157.2500 37.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 51 82.750000 2987.7500 36.1057
Subtotal (Total Children Is Unduplicated) 52 89.750000 3209.7500 35.7632
-----------------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
ASTE-ASTE-ASSISTIVE TECHNOLOGY EVAL 4 4.000000 194.0000 48.5000
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 85 87.000000 720.3600 8.2800
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 52 53.000000 550.1400 10.3800
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 85 86.000000 1812.8800 21.0800
AUDE-92582-CONDITIONED PLAY AUDIOMETRY 1 2.000000 45.9200 22.9600
AUDE-92585-AUD EVOKED RESPONSE (DIAG) 2 2.000000 103.5200 51.7600
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 3 3.000000 81.5700 27.1900
AUDE-92588-OTOACOUSTIC EMISSIONS (COMP) 3 4.000000 121.2400 30.3100
BEHV-H0031HO-COMP BEHAVIORAL HEALTH ASSESSMENT 8 12.000000 1500.0000 125.0000
EXIT-EXIT-TRANSITION ASSESSMENT 6 10.000000 500.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 47 78.333300 5875.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 11 18.500000 1387.5000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 12 18.000000 1325.0000 73.6111
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 26 41.000000 3075.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 37 63.500000 3524.2500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 468 778.839500 58504.6100 75.1177
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 256 406.908000 30446.2400 74.8234
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 119 220.000000 16500.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 409 659.500000 36602.2500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 204 337.205459 25215.4095 74.7776
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 40 40.000000 7400.0000 185.0000
MED-99204-OUTPATIENT VISIT, NEW, 45 MINS 2 2.000000 114.5400 57.2700
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 2 2.000000 210.0000 105.0000
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 2 2.000000 97.0000 48.5000
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 30 30.053710 1457.7199 48.5038
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 2 1.750000 88.8000 50.7429
PSTH-97001-EVAL BY LICENSED PT, INITIAL 17 18.000000 860.5000 47.8056
SCREEN-T1023-INTERDISCIPLINARY SCREENING 4 5.000000 250.0000 50.0000
SENS-V5014TS-HEARING AID REPAIR IN-OFFICE 1 1.000000 15.0000 15.0000
SPCH-92506-SPEECH EVAL BY LICENSED SLP 72 71.138600 3473.0500 48.8209
Subtotal (Total Children Is Unduplicated) 1087 3057.728569 202051.4994 66.0790
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 10 20.000000 5771.2800 288.5640
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 6 11.500000 575.0000 50.0000
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 2 3.500000 175.0000 50.0000
CONOP-CONOP-CONSULT, OT, PHONE 1 1.000000 25.0000 25.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 2 1.250000 63.4100 50.7280
CONPP-CONPP-CONSULT, PT, PHONE 1 1.000000 25.0000 25.0000
CONSP-CONSP-CONSULT, SLP, PHONE 1 1.000000 25.0000 25.0000
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 1 7.000000 175.0000 25.0000
EIIF-96154-HEALTH AND BEHAVIOR INTERVENTION 2 24.000000 1200.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 194 1026.969800 51843.0500 50.4816
HERN-T1027SC-EI HEARING SERVICES AFTER SHINE 3 11.000000 550.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 289 1168.966785 79789.4756 68.2564
OCCT-97530HM-OT SESSION BY OT ASST 26 84.530000 5010.6800 59.2769
PHY-97110-PT SESSION BY LICENSED PT 400 1718.595357 118436.9585 68.9150
PHY-97110HM-PT SESSION BY PT ASST 15 39.961200 2432.7400 60.8776
SENS-HA_EIP-ONE UNIT UP TO $500 PER AID 1 1.000000 500.0000 500.0000
SENS-V5264-EARMOLD 1 1.000000 18.0000 18.0000
SHIN-T1027SC-INITIAL SHINE SERVICES, INDIVIDUAL 4 16.000000 800.0000 50.0000
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 586 2559.911629 175787.5884 68.6694
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 11 23.868200 1296.5200 54.3200
SPL-92508-GROUP SPL SESSION PER CHILD 4 34.000000 448.8000 13.2000
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 10 379.000000 189.5000 0.5000
Subtotal (Total Children Is Unduplicated) 1191 7135.052971 445138.0025 62.3875
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Total 10282.531540 650399.2519 63.2528
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Number of Children (Unduplicated) With at Least One Service 2144
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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 18 40.500000 2348.5800 2348.5800
D 94 123.000000 7282.5000 0.0000
S 0 0.000000 0.0000 0.0000
H 51 67.000000 5400.0000 0.0000
T 2 8.000000 450.0000 500.0000
514 618.250000 43200.5280 0.0000
Other 134 194.750000 11367.3900 0.0000
---------------------------------------------------------
Total 813 1051.500000 70048.9980 2848.5800
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 0 0.000000 0.0000 0.0000
33 26.500000 969.5000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 33 26.500000 969.5000 0.0000
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
164 275.500000 17149.6300 0.0000
Other 75 75.000000 1142.9100 0.0000
---------------------------------------------------------
Total 239 350.500000 18292.5400 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 71 123.000000 8673.5000 12929.5100
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 1 3.000000 203.6400 203.6400
T 0 0.000000 0.0000 0.0000
100 102.000000 8767.0000 0.0000
Other 39 82.000000 5469.2600 5420.7600
---------------------------------------------------------
Total 211 310.000000 23113.4000 18553.9100
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 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
42 33.500000 1716.6000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 42 33.500000 1716.6000 0.0000
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 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
1138 975.250000 63045.7000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 1138 975.250000 63045.7000 0.0000
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 12 36.000000 1978.8000 1978.8000
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
96 194.250000 10483.4800 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 108 230.250000 12462.2800 1978.8000
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 64 176.250000 10630.8900 10807.0800
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
1007 1670.000000 114505.1100 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 1071 1846.250000 125136.0000 10807.0800
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 140 260.500000 16224.2500 8738.0000
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
781 1509.500000 101048.9100 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 921 1770.000000 117273.1600 8738.0000
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 31 111.500000 5886.4000 5884.4000
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
120 336.500000 23204.6100 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 151 448.000000 29091.0100 5884.4000
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 2 4.500000 316.1400 316.1400
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 40 75.250000 4852.9400 0.0000
T 0 0.000000 0.0000 0.0000
281 665.983240 42260.9208 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 323 745.733240 47430.0008 316.1400
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 25 24.750000 1480.5400 1480.5400
D 11 7.250000 330.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 18 18.000000 1043.0400 1043.0400
T 0 0.000000 0.0000 0.0000
374 444.665240 26558.2836 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 428 494.665240 29411.8636 2523.5800
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 11 9.384260 478.8195 478.8200
D 1 1.000000 50.0000 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
631 840.589800 35840.2700 110.9900
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 643 850.974060 36369.0895 589.8100
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 13 11.487999 770.4000 657.9000
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 3 4.500000 337.5000 0.0000
T 0 0.000000 0.0000 0.0000
585 459.605501 31008.7600 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 601 475.593500 32116.6600 657.9000
Center 57
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 0 0.000000 0.0000 0.0000
P 8 13.315500 867.4900 867.4900
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 14 49.500000 2607.6000 2607.6000
315 611.000000 40447.3600 40447.3600
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 337 673.815500 43922.4500 43922.4500