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: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 1 0.250000 9.2500 37.0000
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 9 9.000000 0.0000 0.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 3 2.500000 92.5000 37.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 77 212.000000 7874.0000 37.1415
TCON-TCON-TRANSITION CONFERENCE 2 2.000000 0.0000 0.0000
Subtotal (Total Children Is Unduplicated) 79 225.750000 7975.7500 35.3300
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Screening, Eval, and Assessment,Class #02
AUDE-92552-PURE TONE AUDIOMETRY -AIR ONLY 1 1.000000 11.8600 11.8600
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 86 87.000000 720.3600 8.2800
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 58 58.000000 602.0400 10.3800
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 85 85.000000 1791.8000 21.0800
AUDE-92585-AUD EVOKED RESPONSE (DIAG) 2 2.000000 103.5200 51.7600
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 5 5.000000 135.9500 27.1900
AUDE-V5010-ASSESSMENT FOR HEARING AID 1 1.000000 45.0000 45.0000
BEHV-H0031HO-COMP BEHAVIORAL HEALTH ASSESSMENT 11 22.000000 2750.0000 125.0000
EVAL-EVAL-DEVELOPMENTAL EVALUATION 2 3.000000 150.0000 50.0000
EXIT-EXIT-TRANSITION ASSESSMENT 4 10.000000 500.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 51 91.000000 6698.4300 73.6091
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 16 25.000000 1790.3500 71.6140
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 16 27.500000 2062.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 28 49.500000 3712.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 40 69.000000 3829.5000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 544 904.737934 67389.8700 74.4855
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 262 420.563670 31238.5900 74.2779
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 167 278.500000 20638.8100 74.1070
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 452 749.500000 41536.2500 55.4186
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 223 344.867330 25865.0598 75.0000
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 30 30.000000 5550.0000 185.0000
MED-99204-OUTPATIENT VISIT, NEW, 45 MINS 6 6.000000 996.8100 166.1350
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 38 39.000000 1875.0500 48.0782
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 2 1.999500 96.9800 48.5021
PSTH-97001-EVAL BY LICENSED PT, INITIAL 16 16.000000 776.0000 48.5000
SCREEN-T1023-INTERDISCIPLINARY SCREENING 10 10.000000 500.0000 50.0000
SPCH-92506-SPEECH EVAL BY LICENSED SLP 81 82.000000 4060.4800 49.5180
Subtotal (Total Children Is Unduplicated) 1209 3423.168434 225734.7098 65.9432
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 11 25.150000 8209.8600 326.4358
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 4 2.500000 125.0000 50.0000
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 1 1.000000 50.0000 50.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 2 1.750000 87.5000 50.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 2 1.250000 62.5000 50.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 2 2.000000 100.0000 50.0000
EIIF-96154-HEALTH AND BEHAVIOR INTERVENTION 1 1.000000 50.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 200 933.789800 46501.4600 49.7986
HERN-T1027SC-EI HEARING SERVICES AFTER SHINE 3 6.631200 331.5600 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 292 1242.913423 83397.7292 67.0986
OCCT-97530HM-OT SESSION BY OT ASST 21 84.987900 4516.3200 53.1407
PHY-97110-PT SESSION BY LICENSED PT 405 1847.042007 123989.4100 67.1286
PHY-97110HM-PT SESSION BY PT ASST 9 33.311672 1782.9500 53.5233
SENS-V5264-EARMOLD 1 2.000000 36.0000 18.0000
SHIN-T1027SC-INITIAL SHINE SERVICES, INDIVIDUAL 2 12.000000 600.0000 50.0000
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 614 2448.385877 165922.7603 67.7682
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 3 6.500000 351.9800 54.1508
SPL-92508-GROUP SPL SESSION PER CHILD 8 22.000000 466.0600 21.1845
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 36 1563.000000 781.5000 0.5000
Subtotal (Total Children Is Unduplicated) 1220 8237.211879 437362.5895 53.0960
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Total 11886.130313 671073.0493 56.4585
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Number of Children (Unduplicated) With at Least One Service 2265
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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 20 40.500000 2259.1800 2259.1800
D 101 163.000000 9199.7500 0.0000
S 2 2.000000 100.0000 0.0000
H 52 70.000000 6000.0000 0.0000
T 0 0.000000 0.0000 0.0000
260 228.750000 20828.1000 0.0000
Other 106 126.500000 8983.4800 0.0000
---------------------------------------------------------
Total 541 630.750000 47370.5100 2259.1800
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 3 62.000000 229.0000 229.0000
39 38.500000 1799.8900 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 42 100.500000 2028.8900 229.0000
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
234 1104.750000 18651.4100 0.0000
Other 82 82.000000 1218.9500 0.0000
---------------------------------------------------------
Total 316 1186.750000 19870.3600 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 60 112.500000 7949.3700 10746.6200
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 1 1.000000 67.8800 67.8800
T 0 0.000000 0.0000 0.0000
92 92.500000 8029.7500 0.0000
Other 90 197.500000 13193.1200 12994.3000
---------------------------------------------------------
Total 243 403.500000 29240.1200 23808.8000
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
39 30.250000 1125.3200 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 39 30.250000 1125.3200 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
1110 1001.500000 60127.2500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 1110 1001.500000 60127.2500 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 16 51.000000 2550.0000 2550.0000
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
107 257.500000 15113.5300 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 123 308.500000 17663.5300 2550.0000
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 67 156.000000 9731.2800 10466.6100
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
1065 1855.750000 127609.6900 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 1132 2011.750000 137340.9700 10466.6100
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 6 7.000000 428.5000 314.3500
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
1044 1998.750000 131687.8900 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 1050 2005.750000 132116.3900 314.3500
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 24 76.750000 4113.9700 4113.9700
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
148 407.750000 28831.0900 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 172 484.500000 32945.0600 4113.9700
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 26 45.250000 2350.4300 2267.9300
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 22 39.250000 2551.6500 0.0000
T 0 0.000000 0.0000 0.0000
288 674.585780 44113.6003 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 336 759.085780 49015.6803 2267.9300
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 1 0.449000 22.4500 22.4500
D 5 3.000000 124.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 14 14.000000 771.5200 771.5200
T 15 15.000000 839.4000 839.4000
526 701.931183 35410.4490 0.0000
Other 5 5.000000 250.0000 0.0000
---------------------------------------------------------
Total 566 739.380183 37417.8190 1633.3700
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 8 6.691000 450.5300 450.5300
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 9 192.000000 492.0000 492.0000
T 0 0.000000 0.0000 0.0000
668 907.770170 31850.2600 0.0000
Other 74 82.500000 4549.5000 0.0000
---------------------------------------------------------
Total 759 1188.961170 37342.2900 942.5300
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 1 1.500000 112.5000 145.6200
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 3 5.000000 475.0000 0.0000
T 2 1.000000 67.8800 67.8800
516 437.569280 28523.1000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 522 445.069280 29178.4800 213.5000
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 2 4.883900 331.5200 331.5200
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 12 45.000000 2248.5000 2248.5000
260 540.000000 35710.3600 35779.1800
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 274 589.883900 38290.3800 38359.2000