CMS/EIP Fiscal Report Statewide
Services beginning 01/01/2012 ending 03/31/2012 Date of Report:05/16/2012 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 7675 5803.750000 214545.7500 36.9667
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 3448 3964.000000 0.0000 0.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 6365 7449.250000 275363.7500 36.9653
TCM-T1017TL-TARGETED CASE MANAGEMENT 19491 72675.75000 2686368.5000 36.9638
TCON-TCON-TRANSITION CONFERENCE 597 603.000000 0.0000 0.0000
Subtotal (Total Children Is Unduplicated) 19766 90495.75000 3176278.0000 35.0986
-----------------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
ASTE-ASTE-ASSISTIVE TECHNOLOGY EVAL 16 16.000000 776.0000 48.5000
AUDE-92552-PURE TONE AUDIOMETRY -AIR ONLY 41 42.000000 498.1200 11.8600
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 226 231.000000 1912.6800 8.2800
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 173 176.000000 1826.8800 10.3800
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 227 232.000000 4890.5600 21.0800
AUDE-92582-CONDITIONED PLAY AUDIOMETRY 1 1.000000 22.9600 22.9600
AUDE-92585-AUD EVOKED RESPONSE (DIAG) 4 4.000000 207.0400 51.7600
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 45 45.000000 1223.5500 27.1900
AUDE-92588-OTOACOUSTIC EMISSIONS (COMP) 1 1.000000 30.3100 30.3100
AUDE-V5010-ASSESSMENT FOR HEARING AID 1 1.000000 45.0000 45.0000
AUDE-V5090-DISPENSING FEE PER HEARING AID 1 2.000000 230.0000 115.0000
BEHV-H0031HO-COMP BEHAVIORAL HEALTH ASSESSMENT 28 46.000000 5675.0000 123.3696
EVAL-EVAL-DEVELOPMENTAL EVALUATION 95 124.250000 6117.5000 49.2354
EXIT-EXIT-TRANSITION ASSESSMENT 648 1107.500000 55343.5000 49.9716
IPDEF-IPDEF_NM-F/U PSYCH & DEV EVAL BY NON-MED PROF 5 10.000000 250.0000 25.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 246 416.000000 30867.8500 74.2016
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 63 95.500000 7077.8500 74.1136
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 62 95.000000 7078.4600 74.5101
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 149 254.000000 19131.7500 75.3219
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 279 474.500000 26323.7500 55.4768
IPDEI-IPDEI_NM-INITIAL PSYCH & DEV EVAL BY NON-MED PR 14 24.000000 810.7500 33.7813
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 2407 3709.499904 277058.7700 74.6890
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 862 1379.500000 103046.3200 74.6983
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 566 846.500000 62649.2000 74.0097
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 2677 4302.500000 238569.6200 55.4491
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 1505 2360.999800 178443.2501 75.5795
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 167 167.000000 17023.0000 101.9341
MED-99204-OUTPATIENT VISIT, NEW, 45 MINS 8 8.000000 1111.3500 138.9188
MED-99205-OUTPATIENT VISIT, NEW, 60 MINS 1 1.000000 72.7800 72.7800
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 23 23.000000 1089.2400 47.3583
MED-99214-OUTPATIENT VISIT, EST, 25 MINS 2 2.000000 69.0000 34.5000
MED-99215-OUTPATIENT VISIT, EST, 40 MINS 4 4.000000 200.6000 50.1500
NUTR-97802-NUTRITIONAL EVAL, INITIAL 1 0.750000 37.5000 50.0000
NUTR-97803-NUTRITIONAL EVAL, FOLLOW-UP 1 0.250000 12.5000 50.0000
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 89 93.000000 4510.5000 48.5000
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 132 136.000000 6519.8200 47.9399
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 51 50.999900 2455.1500 48.1403
PSTH-97001-EVAL BY LICENSED PT, INITIAL 94 95.000000 4607.5000 48.5000
SCREEN-T1023-INTERDISCIPLINARY SCREENING 252 253.000000 12650.0000 50.0000
SPCH-92506-SPEECH EVAL BY LICENSED SLP 353 362.000000 17605.4800 48.6339
VISF-VISF-VISION EVALUATION FUNCTIONAL 4 16.500000 900.0000 54.5455
Subtotal (Total Children Is Unduplicated) 5955 17209.24960 1098971.0901 63.8593
-----------------------------------------------------------------------------------------------------------------------
EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 52 127.000000 34375.7000 270.6748
AUD-HA_FUP-AUDIOLOGY SERVICES 1 1.000000 50.0000 50.0000
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 1092 1390.500000 68150.0000 49.0111
COIFP-COIFP-IFSP CONSULT, PRO, BY PHONE 77 58.500000 1458.7500 24.9359
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 745 1009.750000 50475.0000 49.9876
CONIP-CONIP-CONSULT, ITDS, PHONE 153 87.750000 2193.7500 25.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 268 328.000000 16366.2500 49.8971
CONOP-CONOP-CONSULT, OT, PHONE 29 15.250000 381.2500 25.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 284 317.500000 15799.1300 49.7610
CONPP-CONPP-CONSULT, PT, PHONE 52 34.000000 812.5000 23.8971
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 782 887.750000 43379.5000 48.8645
CONSP-CONSP-CONSULT, SLP, PHONE 106 61.500000 1537.5000 25.0000
COUN-H2019HR-INDIVIDUAL/FAMILY THERAPY 8 31.750000 2327.9100 73.3200
ECE-ECE-EARLY CHILDHOOD EDUCATION 94 16588.00000 16588.0000 1.0000
EIGF-EIGF_NM-EI GROUP SESSION BY NONMED PROF 31 2800.000000 70000.0000 25.0000
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 145 2497.000000 62419.3600 24.9977
EIIF-96154-HEALTH AND BEHAVIOR INTERVENTION 40 1043.000000 28090.0000 26.9319
EIIF-EIIF_NM-EI INDIVIDUAL SESSION BY NONMED PROF 21 120.750000 6037.5000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 6508 49461.26000 2461475.6700 49.7657
HERN-T1027SC-EI HEARING SERVICES AFTER SHINE 36 181.500000 9075.0000 50.0000
INTR-INTR-INTERPRETER 393 1656.000000 69958.5900 42.2455
OCCT-97530-OT SESSION BY LICENSED OT 1283 7140.749980 475200.0787 66.5476
OCCT-97530HM-OT SESSION BY OT ASST 87 487.750000 26076.4600 53.4628
PHY-97110-PT SESSION BY LICENSED PT 1634 9517.749690 633017.4300 66.5091
PHY-97110HM-PT SESSION BY PT ASST 81 374.500000 20251.5600 54.0763
SENS-HA_EIP-ONE UNIT UP TO $500 PER AID 1 1.000000 500.0000 500.0000
SENS-HA_INS-SENSORY AID INSURANCE PER EAR 1 2.000000 130.0000 65.0000
CMS/EIP Fiscal Report Statewide
Services beginning 01/01/2012 ending 03/31/2012 Date of Report:05/16/2012 Page: 2
List order: No List
Eligibility Filter:Program Patients
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
SENS-V5050-MED HEARING AID - ANALOG/DIGITAL 2 3.000000 684.0000 228.0000
SENS-V5264-EARMOLD 5 9.000000 162.0000 18.0000
SHIN-T1027SC-INITIAL SHINE SERVICES, INDIVIDUAL 40 146.000000 7300.0000 50.0000
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 2915 17812.77420 1198257.2603 67.2695
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 49 159.000000 8609.7200 54.1492
SPL-92508-GROUP SPL SESSION PER CHILD 50 300.000000 4135.6600 13.7855
TRAN-TRAN-FAMILY TRANSPORTATION 394 729.000000 9294.5000 12.7497
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 10391 2324272.000 1184250.9000 0.5095
VISN-EIIF_NM-EI VISION SERVICES, IND NONMED 50 524.500000 26225.0000 50.0000
VISN-T1027SC-EI VISION SERVICES, INDIVIDUAL 7 17.000000 850.0000 50.0000
Subtotal (Total Children Is Unduplicated) 11965 2440193.784 6555895.9290 2.6866
-----------------------------------------------------------------------------------------------------------------------
Total 2547898.783478 10831145.0191 4.2510
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 20649
-----------------------------------------------------------------------------------------------------------------------
Center 01
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 62 48.750000 1803.7500 0.0000
P 10724 199238.750000 415343.2800 433508.2800
D 243 240.000000 12087.7500 0.0000
S 46 28.500000 1080.5000 0.0000
H 52 70.000000 6000.0000 0.0000
T 2797 100648.750000 133329.4600 133329.4600
7221 16178.000000 357671.2400 0.0000
Other 754 17022.000000 56794.0600 0.0000
---------------------------------------------------------
Total 21899 333474.750000 984110.0400 566837.7400
Center 02
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 1309 1053.000000 38655.7500 0.0000
P 0 0.000000 0.0000 0.0000
D 0 0.000000 0.0000 0.0000
S 1 0.500000 18.5000 0.0000
H 0 0.000000 0.0000 0.0000
T 904 40592.750000 55481.5400 55481.5400
2297 42834.250000 102884.3700 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 4511 84480.500000 197040.1600 55481.5400
Center 03
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 9 5.000000 185.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 374 200.250000 8234.5100 0.0000
P 10619 103284.000000 302771.3900 303982.9210
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 5871 8949.250000 106955.2400 106955.2400
5855 58462.000000 155112.5400 0.0000
Other 189 188.750000 2820.8900 0.0000
---------------------------------------------------------
Total 22917 171089.250000 576079.5700 410938.1610
Center 04
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 2 0.500000 18.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 1287 1288.250000 50488.0000 0.0000
P 8063 170505.500000 427523.7300 388416.8800
D 141 159.500000 5966.5000 425.7500
S 0 0.000000 0.0000 0.0000
H 1952 6471.000000 325632.0600 325696.1000
T 0 0.000000 0.0000 0.0000
5181 9864.000000 326624.0100 0.0000
Other 96 216.500000 14482.8400 13605.2200
---------------------------------------------------------
Total 16722 188505.250000 1150735.6400 728143.9500
Center 05
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 1832 1091.500000 41718.6300 0.0000
P 1402 41152.750000 63687.5600 63687.5600
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
3534 45849.500000 110188.9900 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 6768 88093.750000 215595.1800 63687.5600
Center 06
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 1 0.500000 18.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 23 12.750000 471.7500 18.5000
P 6700 41596.250000 172197.5200 134022.7700
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
15076 88914.250000 485604.8600 481.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 21800 130523.750000 658292.6300 134522.2700
Center 07
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 37 24.250000 897.2500 0.0000
P 8491 166380.000000 392237.8100 392185.0600
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
9266 13741.500000 372864.5200 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 17794 180145.750000 765999.5800 392185.0600
Center 09
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 4833 4867.250000 221074.8000 175.7500
P 16831 258203.750000 821519.5400 821921.6200
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
2995 8789.000000 416927.2500 812.0200
Other 1 2.000000 111.0000 111.0000
---------------------------------------------------------
Total 24660 271862.000000 1459632.5900 823020.3900
Center 10
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 5052 3935.000000 172314.5000 0.0000
P 10272 200935.250000 532152.7600 525511.1100
D 63 57.000000 2983.0000 2946.0000
S 151 80.250000 2969.2500 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
9169 11491.000000 579101.9700 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 24707 216498.500000 1289521.4800 528457.1100
Center 51
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 4043 3040.250000 120441.2500 0.0000
P 2018 111704.500000 182169.3200 182169.3200
D 20 15.000000 740.2800 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
4226 19371.750000 277329.0300 47.5000
Other 31 30.500000 2050.9600 0.0000
---------------------------------------------------------
Total 10338 134162.000000 582730.8400 182216.8200
Center 52
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 98 76.250000 4201.5800 0.0000
P 2896 19773.250000 103540.8400 103361.3400
D 0 0.000000 0.0000 0.0000
S 52 62.750000 4452.0700 0.0000
H 67 112.750000 7252.0600 0.0000
T 0 0.000000 0.0000 0.0000
5432 83295.680004 282340.5903 0.0000
Other 41 99.500000 6679.5400 0.0000
---------------------------------------------------------
Total 8586 103420.180004 408466.6803 103361.3400
Center 53
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 1 0.500000 18.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 678 785.000000 31469.5000 0.0000
P 1841 1739.449000 73630.9500 73556.9500
D 272 251.250000 10604.0000 0.0000
S 514 430.500000 17134.7500 0.0000
H 1223 45081.000000 48725.2400 48725.2400
T 1269 46965.500000 50925.8200 50925.8200
9444 96566.800980 363163.6088 272.0200
Other 5 5.000000 250.0000 0.0000
---------------------------------------------------------
Total 15247 191824.999980 595922.3688 173480.0300
Center 54
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 37 29.500000 1091.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 1664 1209.250000 50464.2500 0.0000
P 3762 2595.691000 106019.2800 104557.7800
D 195 166.750000 8839.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 2443 100459.373620 118545.8200 118421.8200
T 0 0.000000 0.0000 0.0000
8810 66939.434670 328817.6500 0.0000
Other 183 179.250000 9672.7500 0.0000
---------------------------------------------------------
Total 17094 171579.249290 623450.2500 222979.6000
Center 55
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 32 33.000000 1221.0000 0.0000
P 5321 57699.512570 176454.7900 176487.9100
D 59 61.750000 3328.2500 0.0000
S 0 0.000000 0.0000 0.0000
H 4 6.500000 550.0000 0.0000
T 1649 24559.450754 53628.9400 53628.9400
4577 3880.640880 192040.1100 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 11642 86240.854204 427223.0900 230116.8500
Center 57
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 40 32.250000 1193.2500 0.0000
U 0 0.000000 0.0000 0.0000
B 1425 1348.500000 51818.0000 0.0000
P 1559 1736.633900 75990.5200 75962.7700
D 12 9.750000 360.7500 0.0000
S 74 2415.500000 4165.6000 4165.6000
H 0 0.000000 0.0000 0.0000
T 3206 161273.116100 255169.7600 255169.7600
5421 28802.250000 506468.5400 328445.3000
Other 38 380.000000 1178.5000 1178.5000
---------------------------------------------------------
Total 11775 195998.000000 896344.9200 664921.9300