CMS/EIP Fiscal Report Statewide
Services beginning 04/01/2012 ending 06/30/2012 Date of Report:08/16/2012 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 6925 5203.250000 192430.7500 36.9828
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 3015 3443.000000 0.0000 0.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 5445 6303.250000 233093.5000 36.9799
TCM-T1017TL-TARGETED CASE MANAGEMENT 17694 61298.75000 2265863.2500 36.9643
TCON-TCON-TRANSITION CONFERENCE 532 535.000000 0.0000 0.0000
Subtotal (Total Children Is Unduplicated) 18124 76783.25000 2691387.5000 35.0518
-----------------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
ASTE-ASTE-ASSISTIVE TECHNOLOGY EVAL 22 23.000000 1115.5000 48.5000
AUDE-92552-PURE TONE AUDIOMETRY -AIR ONLY 26 26.000000 308.3600 11.8600
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 93 93.000000 770.0400 8.2800
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 86 87.000000 903.0600 10.3800
AUDE-92568-ACOUSTIC REFLEX TESTING (MEMR) 2 2.000000 16.2000 8.1000
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 107 107.000000 2255.5600 21.0800
AUDE-92582-CONDITIONED PLAY AUDIOMETRY 1 1.000000 22.9600 22.9600
AUDE-92585-AUD EVOKED RESPONSE (DIAG) 6 7.000000 362.3200 51.7600
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 24 24.000000 652.5600 27.1900
AUDE-92588-OTOACOUSTIC EMISSIONS (COMP) 5 5.000000 151.5500 30.3100
AUDE-V5090-DISPENSING FEE PER HEARING AID 1 2.000000 230.0000 115.0000
BEHV-BEHV-BEHAVIORAL ASSESSMENT 3 3.000000 375.0000 125.0000
BEHV-H0031HO-COMP BEHAVIORAL HEALTH ASSESSMENT 7 13.000000 1625.0000 125.0000
EVAL-EVAL-DEVELOPMENTAL EVALUATION 102 127.000000 6350.0000 50.0000
EXIT-EXIT-TRANSITION ASSESSMENT 632 1106.750000 55237.5000 49.9096
IPDEF-IPDEF_NM-F/U PSYCH & DEV EVAL BY NON-MED PROF 3 5.500000 150.0000 27.2727
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 226 381.000000 28500.0000 74.8031
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 41 67.000000 5025.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 55 79.999999 6000.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 125 212.500000 15937.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 282 477.000000 26473.5000 55.5000
IPDEI-IPDEI_NM-INITIAL PSYCH & DEV EVAL BY NON-MED PR 6 11.500000 333.2500 28.9783
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 2087 3271.000000 244679.9600 74.8028
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 650 1097.000000 82162.5000 74.8974
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 534 763.500000 57098.4600 74.7851
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 2542 4059.000000 225238.5000 55.4911
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 1246 2072.500000 155324.0000 74.9452
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 187 187.000000 13064.5000 69.8636
MED-99204-OUTPATIENT VISIT, NEW, 45 MINS 3 3.000000 171.8100 57.2700
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 25 25.000000 719.2200 28.7688
MED-99214-OUTPATIENT VISIT, EST, 25 MINS 2 2.000000 69.0000 34.5000
NUTR-97802-NUTRITIONAL EVAL, INITIAL 3 3.000000 150.0000 50.0000
NUTR-97803-NUTRITIONAL EVAL, FOLLOW-UP 2 1.250000 62.5000 50.0000
NUTR-NUTR-UNSPECIFIED NUTRITIONAL EVAL 1 1.000000 50.0000 50.0000
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 54 56.000000 2619.0000 46.7679
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 117 119.000000 5725.3200 48.1119
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 43 44.000000 2037.0000 46.2955
PSTH-97001-EVAL BY LICENSED PT, INITIAL 101 104.000000 4910.7000 47.2183
SCREEN-T1023-INTERDISCIPLINARY SCREENING 258 260.000000 13000.0000 50.0000
SPCH-92506-SPEECH EVAL BY LICENSED SLP 245 252.000000 12222.0000 48.5000
VISF-VISF-VISION EVALUATION FUNCTIONAL 2 5.000000 450.0000 90.0000
Subtotal (Total Children Is Unduplicated) 5306 15186.50000 972549.3300 64.0404
-----------------------------------------------------------------------------------------------------------------------
EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 58 192.000000 38963.8700 202.9368
AUD-HA_FUP-AUDIOLOGY SERVICES 4 4.000000 200.0000 50.0000
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 845 1100.000000 54960.0000 49.9636
COIFP-COIFP-IFSP CONSULT, PRO, BY PHONE 74 55.000000 1375.0000 25.0000
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 805 898.750000 43485.0000 48.3839
CONIP-CONIP-CONSULT, ITDS, PHONE 125 77.500000 1912.5000 24.6774
CONOF-CONOF-CONSULT, OT, FACE TO FACE 396 425.250000 21193.7500 49.8383
CONOP-CONOP-CONSULT, OT, PHONE 41 23.250000 581.2500 25.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 418 393.750000 19662.5000 49.9365
CONPP-CONPP-CONSULT, PT, PHONE 31 16.000000 400.0000 25.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 866 856.000000 42800.0000 50.0000
CONSP-CONSP-CONSULT, SLP, PHONE 94 54.250000 1331.2500 24.5392
COUN-H2019HR-INDIVIDUAL/FAMILY THERAPY 11 43.000000 3116.1000 72.4674
ECE-ECE-EARLY CHILDHOOD EDUCATION 73 11372.00000 11372.0000 1.0000
EIGF-EIGF_NM-EI GROUP SESSION BY NONMED PROF 17 1834.000000 45850.0000 25.0000
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 122 2150.750000 53768.7500 25.0000
EIIF-96154-HEALTH AND BEHAVIOR INTERVENTION 28 195.000000 9750.0000 50.0000
EIIF-EIIF_NM-EI INDIVIDUAL SESSION BY NONMED PROF 22 116.750000 5837.5000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 6553 48452.00000 2421980.1200 49.9872
HERN-T1027SC-EI HEARING SERVICES AFTER SHINE 31 102.500000 5100.0000 49.7561
INTR-INTR-INTERPRETER 302 1362.750000 55091.5500 40.4267
OCCT-97530-OT SESSION BY LICENSED OT 1143 6662.850411 438173.6003 65.7637
OCCT-97530HM-OT SESSION BY OT ASST 65 390.250000 20995.2700 53.7995
PHY-97110-PT SESSION BY LICENSED PT 1563 8465.633740 558691.4410 65.9952
PHY-97110HM-PT SESSION BY PT ASST 67 275.500000 14743.5600 53.5156
SENS-HA_EIP-ONE UNIT UP TO $500 PER AID 1 1.000000 500.0000 500.0000
SENS-V5014-HEARING AID REPAIR BY MANUFACTURER 3 5.000000 570.0000 114.0000
CMS/EIP Fiscal Report Statewide
Services beginning 04/01/2012 ending 06/30/2012 Date of Report:08/16/2012 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 3 9.000000 162.0000 18.0000
SHIN-T1027SC-INITIAL SHINE SERVICES, INDIVIDUAL 36 146.000000 7300.0000 50.0000
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 2655 15657.13497 1056376.6856 67.4693
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 52 174.000000 9465.6900 54.4005
SPL-92508-GROUP SPL SESSION PER CHILD 25 75.250000 993.3000 13.2000
TRAN-TRAN-FAMILY TRANSPORTATION 433 661.000000 3638.0000 5.5038
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 10088 2128611.000 1080758.7000 0.5077
VISN-EIIF_NM-EI VISION SERVICES, IND NONMED 40 414.500000 20725.0000 50.0000
VISN-T1027SC-EI VISION SERVICES, INDIVIDUAL 4 28.000000 1400.0000 50.0000
Subtotal (Total Children Is Unduplicated) 11534 2231303.619 6053908.3869 2.7132
-----------------------------------------------------------------------------------------------------------------------
Total 2323273.369122 9717845.2169 4.1828
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 19414
-----------------------------------------------------------------------------------------------------------------------
Center 01
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 209 163.250000 6040.2500 0.0000
U 0 0.000000 0.0000 0.0000
B 3350 2524.250000 94846.2500 0.0000
P 7011 203008.000000 287448.5700 287760.4800
D 231 237.250000 11214.5000 0.0000
S 280 266.250000 12639.5000 0.0000
H 39 51.500000 3587.5000 0.0000
T 3914 115033.750000 165836.5300 165836.5300
8715 12802.750000 393251.9500 0.0000
Other 508 9246.750000 44232.6200 0.0000
---------------------------------------------------------
Total 24257 343333.750000 1019097.6700 453597.0100
Center 02
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 1 0.250000 9.2500 0.0000
U 0 0.000000 0.0000 0.0000
B 959 810.500000 29840.5000 0.0000
P 0 0.000000 0.0000 0.0000
D 1 0.500000 18.5000 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 963 46689.250000 63915.8200 63915.8200
2598 43656.750000 120281.8300 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 4522 91157.250000 214065.9000 63915.8200
Center 03
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 5 5.250000 251.2500 0.0000
U 0 0.000000 0.0000 0.0000
B 583 404.000000 15873.0000 18.5000
P 8591 95189.250000 248289.8300 248188.1050
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 7219 13103.250000 143900.6600 143900.6600
3775 65486.000000 124184.2700 0.0000
Other 109 107.250000 1746.9700 0.0000
---------------------------------------------------------
Total 20282 174295.000000 534245.9800 392107.2650
Center 04
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 741 894.250000 33438.0000 0.0000
P 8627 177700.750000 463356.5600 423974.0800
D 74 92.500000 3422.5000 3071.0000
S 0 0.000000 0.0000 0.0000
H 2041 6870.250000 341613.4100 303075.4100
T 0 0.000000 0.0000 0.0000
4857 8173.250000 271017.2700 0.0000
Other 80 168.000000 10855.2000 7378.7600
---------------------------------------------------------
Total 16420 193899.000000 1123702.9400 737499.2500
Center 06
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 937 645.750000 23892.7500 138.7500
P 3458 44801.000000 85276.9800 85221.4800
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
3680 8059.750000 132749.9400 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 8075 53506.500000 241919.6700 85360.2300
Center 07
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 40 27.250000 1047.2500 0.0000
U 0 0.000000 0.0000 0.0000
B 20 13.000000 481.0000 0.0000
P 8292 167890.750000 391492.1600 391491.6600
D 1 1.000000 37.0000 0.0000
S 1 1.250000 46.2500 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
8545 15747.000000 378005.5800 0.0000
Other 1 0.750000 27.7500 0.0000
---------------------------------------------------------
Total 16900 183681.000000 771136.9900 391491.6600
Center 09
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 5717 5703.500000 254527.8000 0.0000
P 15673 242490.000000 733261.8700 734739.3700
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
3206 19531.750000 441191.6800 856.8100
Other 1 1.000000 37.0000 0.0000
---------------------------------------------------------
Total 24597 267726.250000 1429018.3500 735596.1800
Center 10
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 77 54.750000 2025.7500 0.0000
U 0 0.000000 0.0000 0.0000
B 8146 6004.250000 235539.5000 0.0000
P 6718 224271.250000 491060.7500 491060.7500
D 21 11.250000 416.2500 416.2500
S 43 23.500000 869.5000 0.0000
H 2 5.750000 212.7500 0.0000
T 1 0.500000 18.5000 0.0000
9000 12379.250000 632837.4000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 24008 242750.500000 1362980.4000 491477.0000
Center 51
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 3558 2628.500000 104373.5000 0.0000
P 1613 88179.250000 130489.4200 130139.5200
D 15 14.500000 574.5000 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
3693 20550.000000 233716.0600 0.0000
Other 18 29.500000 1964.5100 0.0000
---------------------------------------------------------
Total 8897 111401.750000 471117.9900 130139.5200
Center 52
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 51 37.750000 2526.7900 0.0000
P 975 759.750000 33700.3900 33700.3900
D 0 0.000000 0.0000 0.0000
S 8 14.790218 884.6600 0.0000
H 42 83.750000 5313.2500 0.0000
T 0 0.000000 0.0000 0.0000
2092 33212.469780 92987.2599 0.0000
Other 21 33.500000 2205.3200 0.0000
---------------------------------------------------------
Total 3189 34142.009998 137617.6699 33700.3900
Center 53
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 2 2.500000 133.2500 0.0000
U 0 0.000000 0.0000 0.0000
B 755 642.250000 23834.5000 37.0000
P 3427 48279.581010 146191.5050 146154.0100
D 7 6.000000 298.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 1534 52286.193135 54263.4200 54263.4200
8310 77195.610825 324765.0779 168.0000
Other 39 43.000000 2425.0000 0.0000
---------------------------------------------------------
Total 14074 178455.134970 551910.7529 200622.4300
Center 54
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 2 3.000000 161.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 1367 1078.000000 47028.2500 0.0000
P 5000 54418.402846 172624.9100 190536.0900
D 4 2.750000 127.7500 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 2295 45282.700090 75553.4013 75553.4000
7255 78730.770799 304065.6400 0.0000
Other 133 165.500000 9968.5000 9.2500
---------------------------------------------------------
Total 16056 179681.123735 609529.4513 266098.7400
Center 55
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 31 22.750000 841.7500 0.0000
P 4873 54283.604252 167388.5300 167456.0300
D 50 60.250000 3483.2500 0.0000
S 1 0.750000 27.7500 0.0000
H 4 6.500000 587.5000 0.0000
T 1597 24486.821642 49339.1800 49339.1800
4667 4011.674525 197518.1228 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 11223 82872.350419 419186.0828 216795.2100
Center 57
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 52 67.000000 2544.7500 0.0000
U 0 0.000000 0.0000 0.0000
B 1483 1491.750000 57415.2500 112.5000
P 988 991.750000 45781.0700 45709.8200
D 5 4.750000 175.7500 0.0000
S 60 1712.000000 3760.8400 3760.8400
H 3 3.750000 233.7500 0.0000
T 3329 160095.250000 274558.9500 274641.0600
4723 21775.500000 447091.9700 295737.3900
Other 12 230.000000 753.0400 753.0400
---------------------------------------------------------
Total 10655 186371.750000 832315.3700 620714.6500