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
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 7675 5803.500000 214536.5000 36.9667
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 3442 3955.000000 0.0000 0.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 6363 7446.750000 275271.2500 36.9653
TCM-T1017TL-TARGETED CASE MANAGEMENT 7332 25719.00000 950537.0000 36.9586
TCON-TCON-TRANSITION CONFERENCE 596 601.000000 0.0000 0.0000
Subtotal (Total Children Is Unduplicated) 14808 43525.25000 1440344.7500 33.0922
-----------------------------------------------------------------------------------------------------------------------
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 40 41.000000 486.2600 11.8600
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 53 54.000000 447.1200 8.2800
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 56 57.000000 591.6600 10.3800
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 54 56.000000 1180.4800 21.0800
AUDE-92585-AUD EVOKED RESPONSE (DIAG) 1 1.000000 51.7600 51.7600
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 37 37.000000 1006.0300 27.1900
AUDE-92588-OTOACOUSTIC EMISSIONS (COMP) 1 1.000000 30.3100 30.3100
AUDE-V5090-DISPENSING FEE PER HEARING AID 1 2.000000 230.0000 115.0000
BEHV-H0031HO-COMP BEHAVIORAL HEALTH ASSESSMENT 13 16.000000 1925.0000 120.3125
EVAL-EVAL-DEVELOPMENTAL EVALUATION 95 121.250000 5967.5000 49.2165
EXIT-EXIT-TRANSITION ASSESSMENT 644 1097.500000 54843.5000 49.9713
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 47 79.500000 5856.9200 73.6719
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 13 18.500000 1340.9600 72.4843
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 47 65.500000 4994.2500 76.2481
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 48 88.000000 4884.0000 55.5000
IPDEI-IPDEI_NM-INITIAL PSYCH & DEV EVAL BY NON-MED PR 1 1.500000 83.2500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 524 757.261970 56606.4000 74.7514
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 128 198.436330 14845.2300 74.8110
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 89 109.500000 7747.8900 70.7570
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 577 956.000000 53016.3700 55.4565
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 493 690.132470 53128.1903 76.9826
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 6 6.000000 243.0000 40.5000
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 39 39.000000 1891.5000 48.5000
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 45 46.000000 2171.2700 47.2015
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 20 19.000400 903.1700 47.5343
PSTH-97001-EVAL BY LICENSED PT, INITIAL 32 32.000000 1552.0000 48.5000
SCREEN-T1023-INTERDISCIPLINARY SCREENING 135 136.000000 6800.0000 50.0000
SPCH-92506-SPEECH EVAL BY LICENSED SLP 155 158.000000 7628.0000 48.2785
VISF-VISF-VISION EVALUATION FUNCTIONAL 4 16.500000 900.0000 54.5455
Subtotal (Total Children Is Unduplicated) 2452 4936.081170 293565.5203 59.4734
-----------------------------------------------------------------------------------------------------------------------
EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 46 99.850000 24237.8400 242.7425
AUD-HA_FUP-AUDIOLOGY SERVICES 1 1.000000 50.0000 50.0000
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 1091 1388.000000 68025.0000 49.0094
COIFP-COIFP-IFSP CONSULT, PRO, BY PHONE 77 58.500000 1458.7500 24.9359
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 743 1006.750000 50325.0000 49.9876
CONIP-CONIP-CONSULT, ITDS, PHONE 153 87.750000 2193.7500 25.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 266 326.250000 16278.7500 49.8966
CONOP-CONOP-CONSULT, OT, PHONE 29 15.250000 381.2500 25.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 282 315.000000 15674.1300 49.7591
CONPP-CONPP-CONSULT, PT, PHONE 52 34.000000 812.5000 23.8971
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 755 851.750000 41579.5000 48.8166
CONSP-CONSP-CONSULT, SLP, PHONE 105 60.500000 1512.5000 25.0000
COUN-H2019HR-INDIVIDUAL/FAMILY THERAPY 8 31.750000 2327.9100 73.3200
EIGF-EIGF_NM-EI GROUP SESSION BY NONMED PROF 2 4.000000 100.0000 25.0000
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 37 162.000000 4044.3600 24.9652
EIIF-96154-HEALTH AND BEHAVIOR INTERVENTION 39 922.000000 22340.0000 24.2299
EIIF-EIIF_NM-EI INDIVIDUAL SESSION BY NONMED PROF 5 19.000000 950.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 2396 17266.47020 852099.2100 49.3499
HERN-T1027SC-EI HEARING SERVICES AFTER SHINE 8 39.868800 1993.4400 50.0000
INTR-INTR-INTERPRETER 391 1651.000000 69858.5900 42.3129
OCCT-97530-OT SESSION BY LICENSED OT 560 2971.336557 193205.7695 65.0232
OCCT-97530HM-OT SESSION BY OT ASST 54 241.262100 12787.4600 53.0024
PHY-97110-PT SESSION BY LICENSED PT 690 3749.707683 242924.7800 64.7850
PHY-97110HM-PT SESSION BY PT ASST 22 91.938328 4929.3500 53.6158
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
SENS-V5050-MED HEARING AID - ANALOG/DIGITAL 2 3.000000 684.0000 228.0000
SENS-V5264-EARMOLD 4 7.000000 126.0000 18.0000
SHIN-T1027SC-INITIAL SHINE SERVICES, INDIVIDUAL 26 115.000000 5750.0000 50.0000
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 1589 10053.08973 671858.2300 66.8310
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 45 146.500000 7931.8200 54.1421
SPL-92508-GROUP SPL SESSION PER CHILD 1 1.000000 13.2000 13.2000
TRAN-TRAN-FAMILY TRANSPORTATION 394 729.000000 9294.5000 12.7497
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 10360 2310402.000 1177236.9000 0.5095
VISN-EIIF_NM-EI VISION SERVICES, IND NONMED 7 22.000000 1100.0000 50.0000
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
Payclass Filters:GR
Eligibility Filter:Program Patients
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Subtotal (Total Children Is Unduplicated) 11298 2352876.523 3504714.4895 1.4895
-----------------------------------------------------------------------------------------------------------------------
Total 2401337.854565 5238624.7598 2.1815
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 17854
-----------------------------------------------------------------------------------------------------------------------
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 4798 194573.500000 231060.6000 230995.8500
D 31 10.000000 370.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 2797 100648.750000 133329.4600 133329.4600
5114 11963.000000 133302.0700 0.0000
Other 375 16512.000000 21297.4000 0.0000
---------------------------------------------------------
Total 13115 323707.250000 519359.5300 364325.3100
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 901 40530.750000 55252.5400 55252.5400
2108 42547.500000 84315.2300 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 3009 83078.250000 139567.7700 55252.5400
Center 03
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 1 0.250000 9.2500 0.0000
P 5908 100325.500000 183238.6400 183488.1900
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 5871 8949.250000 106955.2400 106955.2400
5621 57357.250000 136461.1300 0.0000
Other 2 2.000000 29.3600 0.0000
---------------------------------------------------------
Total 17403 166634.250000 426693.6200 290443.4300
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 3394 165507.250000 226651.6600 189796.2500
D 139 154.500000 5716.5000 175.7500
S 0 0.000000 0.0000 0.0000
H 101 373.000000 16089.1400 16064.9600
T 0 0.000000 0.0000 0.0000
3994 3343.250000 103465.2500 0.0000
Other 6 19.000000 1289.7200 610.9200
---------------------------------------------------------
Total 7634 169397.000000 353212.2700 206647.8800
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 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
3486 45811.750000 108577.1700 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 4888 86964.500000 172264.7300 63687.5600
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 2737 38813.750000 69245.0200 69245.0200
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
11022 84958.250000 272958.4900 481.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 13759 123772.000000 342203.5100 69726.0200
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 2977 162342.500000 230359.3100 230334.3100
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
7904 10039.250000 180079.5000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 10881 172381.750000 410438.8100 230334.3100
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 14904 256231.250000 736516.7600 736470.5100
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
232 2108.750000 13328.4200 812.0200
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 15136 258340.000000 749845.1800 737282.5300
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 5001 197081.500000 379004.0100 372976.5100
D 45 32.250000 1193.2500 1174.7500
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
6374 4792.250000 179087.5700 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 11420 201906.000000 559284.8300 374151.2600
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 1994 111627.750000 178055.3500 178055.3500
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
3071 16160.750000 80943.3400 47.5000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 5085 127803.500000 259738.9700 178102.8500
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 368 17958.500000 23640.7900 23640.7900
D 0 0.000000 0.0000 0.0000
S 3 1.500000 55.5000 0.0000
H 2 4.000000 300.0000 0.0000
T 0 0.000000 0.0000 0.0000
4565 73976.594224 159079.0500 0.0000
Other 41 99.500000 6679.5400 0.0000
---------------------------------------------------------
Total 4979 92040.094224 189754.8800 23640.7900
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 46 42.500000 1953.5000 0.0000
S 0 0.000000 0.0000 0.0000
H 1209 45067.000000 47953.7200 47953.7200
T 1254 46950.500000 50086.4200 50086.4200
6152 93050.869797 173490.6398 0.5000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 8661 185110.869797 273484.2798 98040.6400
Center 54
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 1 0.250000 9.2500 0.0000
P 0 0.000000 0.0000 0.0000
D 191 165.500000 8792.7500 0.0000
S 0 0.000000 0.0000 0.0000
H 2434 100267.373620 118053.8200 117929.8200
T 0 0.000000 0.0000 0.0000
5333 61246.615900 137149.1500 0.0000
Other 39 35.000000 1764.0000 0.0000
---------------------------------------------------------
Total 7998 161714.739520 265768.9700 117929.8200
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 3423 55854.262570 104417.2900 104417.2900
D 59 61.750000 3328.2500 0.0000
S 0 0.000000 0.0000 0.0000
H 1 1.500000 75.0000 0.0000
T 1647 24558.450754 53561.0600 53561.0600
1856 1527.571600 41723.9400 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 6986 82003.534924 203105.5400 157978.3500
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 1 0.250000 9.2500 9.2500
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 3192 161219.116100 252471.2600 252471.2600
2925 2797.500000 116775.0100 248.5000
Other 4 42.000000 120.0000 120.0000
---------------------------------------------------------
Total 6208 166484.116100 373901.8700 257014.6100