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
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 6925 5202.750000 192412.2500 36.9828
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 3015 3442.000000 0.0000 0.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 5445 6303.250000 233093.5000 36.9799
TCM-T1017TL-TARGETED CASE MANAGEMENT 6532 20970.25000 775080.0000 36.9609
TCON-TCON-TRANSITION CONFERENCE 532 535.000000 0.0000 0.0000
Subtotal (Total Children Is Unduplicated) 13375 36453.25000 1200585.7500 32.9349
-----------------------------------------------------------------------------------------------------------------------
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) 29 29.000000 240.1200 8.2800
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 44 44.000000 456.7200 10.3800
AUDE-92568-ACOUSTIC REFLEX TESTING (MEMR) 2 2.000000 16.2000 8.1000
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 44 44.000000 927.5200 21.0800
AUDE-92582-CONDITIONED PLAY AUDIOMETRY 1 1.000000 22.9600 22.9600
AUDE-92585-AUD EVOKED RESPONSE (DIAG) 2 2.000000 103.5200 51.7600
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 22 22.000000 598.1800 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 5 9.000000 1125.0000 125.0000
EVAL-EVAL-DEVELOPMENTAL EVALUATION 90 105.500000 5275.0000 50.0000
EXIT-EXIT-TRANSITION ASSESSMENT 629 1098.250000 54812.5000 49.9089
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 50 83.870500 6252.7800 74.5528
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 7 7.500000 562.5000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 8 10.901866 815.2100 74.7771
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 42 59.460533 4459.5400 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 50 85.500000 4745.2500 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 514 761.684900 56403.2450 74.0506
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 113 190.732000 14267.4000 74.8034
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 89 111.272433 8200.8900 73.7010
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 514 832.000000 46140.0000 55.4567
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 439 619.457867 46421.8400 74.9395
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 3 3.000000 121.5000 40.5000
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 30 31.000000 1406.5000 45.3710
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 60 59.278350 2828.9200 47.7227
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 12 13.000000 533.5000 41.0385
PSTH-97001-EVAL BY LICENSED PT, INITIAL 45 46.793900 2136.2000 45.6512
SCREEN-T1023-INTERDISCIPLINARY SCREENING 131 133.000000 6650.0000 50.0000
SPCH-92506-SPEECH EVAL BY LICENSED SLP 115 116.072200 5629.5000 48.5000
VISF-VISF-VISION EVALUATION FUNCTIONAL 2 5.000000 450.0000 90.0000
Subtotal (Total Children Is Unduplicated) 2294 4592.024549 274128.6550 59.6967
-----------------------------------------------------------------------------------------------------------------------
EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 48 154.000000 26592.7100 172.6799
AUD-HA_FUP-AUDIOLOGY SERVICES 4 4.000000 200.0000 50.0000
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 833 1029.250000 51422.5000 49.9611
COIFP-COIFP-IFSP CONSULT, PRO, BY PHONE 74 55.000000 1375.0000 25.0000
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 784 865.750000 41825.0000 48.3107
CONIP-CONIP-CONSULT, ITDS, PHONE 122 74.500000 1837.5000 24.6644
CONOF-CONOF-CONSULT, OT, FACE TO FACE 388 409.250000 20393.7500 49.8320
CONOP-CONOP-CONSULT, OT, PHONE 41 23.250000 581.2500 25.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 414 388.500000 19400.0000 49.9356
CONPP-CONPP-CONSULT, PT, PHONE 31 16.000000 400.0000 25.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 839 808.250000 40412.5000 50.0000
CONSP-CONSP-CONSULT, SLP, PHONE 92 52.250000 1281.2500 24.5215
COUN-H2019HR-INDIVIDUAL/FAMILY THERAPY 11 33.000000 2419.5600 73.3200
EIGF-EIGF_NM-EI GROUP SESSION BY NONMED PROF 1 4.000000 100.0000 25.0000
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 30 124.750000 3118.7500 25.0000
EIIF-96154-HEALTH AND BEHAVIOR INTERVENTION 26 181.000000 9050.0000 50.0000
EIIF-EIIF_NM-EI INDIVIDUAL SESSION BY NONMED PROF 4 12.000000 600.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 2175 15788.16500 788694.4300 49.9548
HERN-T1027SC-EI HEARING SERVICES AFTER SHINE 11 37.000000 1825.0000 49.3243
INTR-INTR-INTERPRETER 300 1230.750000 48975.9900 39.7936
OCCT-97530-OT SESSION BY LICENSED OT 570 3064.326123 195183.4803 63.6954
OCCT-97530HM-OT SESSION BY OT ASST 34 168.779480 8993.6300 53.2863
PHY-97110-PT SESSION BY LICENSED PT 679 3311.030620 209921.2210 63.4006
PHY-97110HM-PT SESSION BY PT ASST 18 60.750000 3062.6600 50.4142
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
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 21 108.500000 5425.0000 50.0000
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 1574 9116.257324 611346.6112 67.0611
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 41 144.000000 7822.0800 54.3200
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
Payclass Filters:GR
Eligibility Filter:Program Patients
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
SPL-92508-GROUP SPL SESSION PER CHILD 5 15.500000 204.6000 13.2000
TRAN-TRAN-FAMILY TRANSPORTATION 433 661.000000 3638.0000 5.5038
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 10053 2109850.000 1071372.2000 0.5078
VISN-EIIF_NM-EI VISION SERVICES, IND NONMED 7 21.000000 1050.0000 50.0000
Subtotal (Total Children Is Unduplicated) 10973 2147829.809 3180440.6725 1.4808
-----------------------------------------------------------------------------------------------------------------------
Total 2188875.083096 4655155.0775 2.1267
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 16729
-----------------------------------------------------------------------------------------------------------------------
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 4581 200974.750000 207794.5300 207794.5300
D 35 13.500000 499.5000 0.0000
S 92 58.250000 2155.2500 0.0000
H 0 0.000000 0.0000 0.0000
T 3913 115029.750000 165636.5300 165636.5300
5748 8251.500000 143455.0600 0.0000
Other 215 8817.750000 13647.2000 0.0000
---------------------------------------------------------
Total 14584 333145.500000 533188.0700 373431.0600
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 957 46678.250000 63294.3000 63294.3000
2199 43216.500000 96217.7600 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 3156 89894.750000 159512.0600 63294.3000
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 5233 92955.750000 157123.0800 157123.0800
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 7219 13103.250000 143900.6600 143900.6600
2739 50086.750000 83332.7500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 15191 156145.750000 384356.4900 301023.7400
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 3562 172123.000000 245890.0200 205830.9600
D 8 9.500000 351.5000 0.0000
S 0 0.000000 0.0000 0.0000
H 10 176.500000 931.8200 685.5200
T 0 0.000000 0.0000 0.0000
3798 3408.750000 103995.5000 0.0000
Other 6 12.000000 814.5600 509.1000
---------------------------------------------------------
Total 7384 175729.750000 351983.4000 207025.5800
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 3057 44540.250000 75629.2300 75629.2300
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
2267 6711.000000 59020.8600 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 5324 51251.250000 134650.0900 75629.2300
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 3197 164157.500000 240615.4100 240614.9100
D 1 1.000000 37.0000 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
7094 11473.500000 167476.5000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 10292 175632.000000 408128.9100 240614.9100
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 15259 241777.000000 691160.2200 691014.2800
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
473 12721.000000 34933.5200 129.7600
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 15732 254498.000000 726093.7400 691144.0400
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 5813 223195.000000 429248.2500 429248.2500
D 19 10.500000 388.5000 388.5000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
5916 4725.250000 181217.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 11748 227930.750000 610853.7500 429636.7500
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 1597 88123.250000 127493.6500 127543.7500
D 14 13.500000 499.5000 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
2798 17921.250000 76587.2100 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 4409 106058.000000 204580.3600 127543.7500
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 0 0.000000 0.0000 0.0000
D 0 0.000000 0.0000 0.0000
S 6 10.790218 623.6600 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
1819 31670.275000 57103.1500 0.0000
Other 19 29.500000 1944.3200 0.0000
---------------------------------------------------------
Total 1844 31710.565218 59671.1300 0.0000
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 1195 46043.581010 50100.9750 50100.9800
D 6 4.000000 148.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 1511 52263.193135 53041.9000 53041.9000
5406 74181.201500 157840.9084 168.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 8118 172491.975645 261131.7834 103310.8800
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 1226 51644.159346 60332.9200 60295.9200
D 2 2.000000 100.0000 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
3890 74557.043170 109400.5300 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 7413 171485.902606 245386.8513 135849.3200
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 3368 52702.022652 104941.8500 104941.8500
D 50 60.250000 3483.2500 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 1594 24483.821642 49135.5400 49135.5400
1837 1515.545333 41879.5528 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 6849 78761.639627 199440.1928 154077.3900
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 0 0.000000 0.0000 0.0000
D 5 4.750000 175.7500 0.0000
S 58 1708.000000 3516.4400 3516.4400
H 0 0.000000 0.0000 0.0000
T 3310 160028.750000 271207.1300 271289.2400
2594 2397.750000 101278.9300 150.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 5967 164139.250000 376178.2500 274955.6800