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:TPIN
Eligibility Filter:Program Patients
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 23 64.750000 2377.2500 36.7143
Subtotal (Total Children Is Unduplicated) 23 64.750000 2377.2500 36.7143
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Screening, Eval, and Assessment,Class #02
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 19 19.000000 157.3200 8.2800
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 13 13.000000 134.9400 10.3800
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 19 19.000000 400.5200 21.0800
AUDE-92585-AUD EVOKED RESPONSE (DIAG) 1 1.000000 51.7600 51.7600
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 1 1.000000 27.1900 27.1900
BEHV-H0031HO-COMP BEHAVIORAL HEALTH ASSESSMENT 1 2.000000 250.0000 125.0000
EVAL-EVAL-DEVELOPMENTAL EVALUATION 12 21.500000 1075.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 58 103.129500 7734.7200 75.0001
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 4 6.500000 487.5000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 11 17.098133 1284.7900 75.1421
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 35 64.039467 4802.9600 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 36 63.000000 3496.5000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 405 684.315100 51439.2150 75.1689
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 143 242.768000 18207.6000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 132 218.227567 16347.5700 74.9107
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 456 756.000000 41958.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 193 307.542133 23065.6600 75.0000
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 39 39.000000 7070.5000 181.2949
MED-99204-OUTPATIENT VISIT, NEW, 45 MINS 3 3.000000 171.8100 57.2700
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 2 2.000000 210.0000 105.0000
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 1 1.000000 48.5000 48.5000
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 22 21.721650 1053.4000 48.4954
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 1 1.000000 48.5000 48.5000
PSTH-97001-EVAL BY LICENSED PT, INITIAL 15 14.206100 689.0000 48.5003
SCREEN-T1023-INTERDISCIPLINARY SCREENING 7 7.000000 350.0000 50.0000
SPCH-92506-SPEECH EVAL BY LICENSED SLP 47 46.927800 2276.0000 48.5000
Subtotal (Total Children Is Unduplicated) 965 2674.975450 182838.9550 68.3516
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 13 26.000000 7406.0900 284.8496
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 19 70.750000 3537.5000 50.0000
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 33 31.500000 1585.0000 50.3175
CONIP-CONIP-CONSULT, ITDS, PHONE 3 3.000000 75.0000 25.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 13 13.000000 650.0000 50.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 5 4.500000 225.0000 50.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 21 17.000000 850.0000 50.0000
CONSP-CONSP-CONSULT, SLP, PHONE 2 2.000000 50.0000 25.0000
EIIF-96154-HEALTH AND BEHAVIOR INTERVENTION 3 14.000000 700.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 300 1125.835000 56583.6900 50.2593
HERN-T1027SC-EI HEARING SERVICES AFTER SHINE 1 4.000000 200.0000 50.0000
INTR-INTR-INTERPRETER 19 130.000000 6015.5600 46.2735
OCCT-97530-OT SESSION BY LICENSED OT 237 1136.992254 75977.8300 66.8235
OCCT-97530HM-OT SESSION BY OT ASST 22 109.470520 5917.8000 54.0584
PHY-97110-PT SESSION BY LICENSED PT 388 1600.141840 107493.8000 67.1777
PHY-97110HM-PT SESSION BY PT ASST 10 42.250000 2310.7000 54.6911
SHIN-T1027SC-INITIAL SHINE SERVICES, INDIVIDUAL 3 11.000000 550.0000 50.0000
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 513 2041.492048 139611.7744 68.3871
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 8 12.000000 665.8500 55.4875
SPL-92508-GROUP SPL SESSION PER CHILD 2 10.000000 132.0000 13.2000
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 212 15099.00000 7555.5000 0.5004
Subtotal (Total Children Is Unduplicated) 1346 21503.93166 418093.0944 19.4426
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Total 24243.657112 603309.2994 24.8852
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Number of Children (Unduplicated) With at Least One Service 2175
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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 37.500000 2055.5400 2367.4500
D 87 131.500000 7301.7500 0.0000
S 1 1.000000 55.5000 0.0000
H 39 51.500000 3587.5000 0.0000
T 1 4.000000 200.0000 200.0000
471 475.750000 36500.7900 0.0000
Other 103 137.000000 9607.1000 0.0000
---------------------------------------------------------
Total 722 838.250000 59308.1800 2567.4500
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 6 11.000000 621.5200 621.5200
14 15.750000 856.0700 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 20 26.750000 1477.5900 621.5200
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
1018 15265.000000 40259.2700 0.0000
Other 23 23.000000 374.3300 0.0000
---------------------------------------------------------
Total 1041 15288.000000 40633.6000 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 43 125.250000 7036.9500 7217.8700
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 3 12.000000 671.5200 671.5200
T 0 0.000000 0.0000 0.0000
134 132.000000 12406.2500 0.0000
Other 72 152.500000 9803.0600 6869.6600
---------------------------------------------------------
Total 252 421.750000 29917.7800 14759.0500
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
326 303.250000 18602.8000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 326 303.250000 18602.8000 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 12 37.000000 1861.0000 1861.0000
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
151 635.250000 23151.7200 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 163 672.250000 25012.7200 1861.0000
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 94 213.000000 13464.5200 14713.4600
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
977 1710.500000 117466.2000 727.0500
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 1071 1923.500000 130930.7200 15440.5100
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 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
1058 2028.750000 134243.6600 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 1058 2028.750000 134243.6600 0.0000
Center 51
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 0 0.000000 0.0000 0.0000
P 13 44.000000 2395.7700 2395.7700
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
86 212.000000 14169.1200 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 99 256.000000 16564.8900 2395.7700
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 0 0.000000 0.0000 0.0000
H 13 24.750000 1408.6700 0.0000
T 0 0.000000 0.0000 0.0000
71 158.504780 10258.8599 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 84 183.254780 11667.5299 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 22 23.000000 1305.7800 1305.7800
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 23 23.000000 1221.5200 1221.5200
477 539.909325 32282.9995 0.0000
Other 1 0.500000 25.0000 0.0000
---------------------------------------------------------
Total 523 586.409325 34835.2995 2527.3000
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 34 17.993500 1153.7400 1153.6700
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
585 734.270829 35881.5800 0.0000
Other 68 88.000000 5167.0000 0.0000
---------------------------------------------------------
Total 687 840.264329 42202.3200 1153.6700
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 14 8.331600 583.9300 651.4300
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 4 6.500000 587.5000 0.0000
T 3 3.000000 203.6400 203.6400
467 411.897078 27460.9600 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 488 429.728678 28836.0300 855.0700
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 1.500000 101.8200 101.8200
D 0 0.000000 0.0000 0.0000
S 2 4.000000 244.4000 244.4000
H 0 0.000000 0.0000 0.0000
T 12 46.500000 2351.8200 2351.8200
197 392.500000 26310.2600 25918.7600
Other 1 1.000000 67.8800 67.8800
---------------------------------------------------------
Total 213 445.500000 29076.1800 28684.6800