CMS/EIP Fiscal Report Statewide
Services beginning 07/01/2012 ending 09/30/2012 Date of Report:11/16/2012 Page: 1
List order: No List
Payclass Filters:TPIN
Eligibility Filter:Part C (excluding not eligible)
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
CASE-CASE-NON-TCM CASE MANAGEMENT 6 6.250000 231.2500 37.0000
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 1 1.000000 0.0000 0.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 4 4.000000 148.0000 37.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 39 104.000000 3857.2500 37.0889
TCON-TCON-TRANSITION CONFERENCE 1 1.000000 0.0000 0.0000
Subtotal (Total Children Is Unduplicated) 42 116.250000 4236.5000 36.4430
-----------------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
AUDE-92552-PURE TONE AUDIOMETRY -AIR ONLY 2 2.000000 13.0700 6.5350
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 31 31.000000 273.2800 8.8155
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 12 12.000000 110.2400 9.1867
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 30 31.000000 664.0400 21.4206
AUDE-92585-AUD EVOKED RESPONSE (DIAG) 1 1.000000 56.9400 56.9400
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 2 2.000000 51.6600 25.8300
AUDE-V5090-DISPENSING FEE PER HEARING AID 1 2.000000 230.0000 115.0000
EVAL-EVAL-DEVELOPMENTAL EVALUATION 2 3.500000 175.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 47 85.500000 6417.0600 75.0533
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 8 14.500000 1087.5000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 6 11.500000 862.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 27 50.500000 3787.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 23 38.000000 2139.7800 56.3100
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 245 435.968600 32697.6600 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 114 197.214400 14791.0800 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 83 138.388933 10379.1700 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 253 437.000000 24253.5000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 144 231.731868 17379.8900 75.0000
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 16 16.000000 4480.0000 280.0000
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 2 2.000000 360.0000 180.0000
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 2 2.000000 97.0000 48.5000
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 13 14.000000 655.5000 46.8214
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 3 3.000000 145.5000 48.5000
PSTH-97001-EVAL BY LICENSED PT, INITIAL 11 11.000000 533.5000 48.5000
SCREEN-T1023-INTERDISCIPLINARY SCREENING 3 3.000000 150.0000 50.0000
SPCH-92506-SPEECH EVAL BY LICENSED SLP 34 32.999999 1600.5000 48.5000
Subtotal (Total Children Is Unduplicated) 625 1808.803800 123391.8700 68.2174
-----------------------------------------------------------------------------------------------------------------------
EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 11 41.000000 20883.7800 509.3605
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 3 3.000000 150.0000 50.0000
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 1 1.000000 50.0000 50.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 1 1.000000 50.0000 50.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 1 1.000000 50.0000 50.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 1 1.000000 50.0000 50.0000
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 1 1.000000 25.0000 25.0000
EIIF-96154-HEALTH AND BEHAVIOR INTERVENTION 16 146.500000 7328.6100 50.0246
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 208 918.789800 46101.1200 50.1759
HERN-T1027SC-EI HEARING SERVICES AFTER SHINE 3 6.000000 300.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 146 615.609422 41481.4000 67.3827
OCCT-97530HM-OT SESSION BY OT ASST 10 37.750000 2046.2600 54.2056
PHY-97110-PT SESSION BY LICENSED PT 225 956.880371 64637.1900 67.5499
PHY-97110HM-PT SESSION BY PT ASST 8 22.500000 1240.4800 55.1324
SENS-HA_EIP-ONE UNIT UP TO $500 PER AID 1 2.000000 1000.0000 500.0000
SHIN-T1027SC-INITIAL SHINE SERVICES, INDIVIDUAL 4 10.000000 500.0000 50.0000
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 337 1551.152987 105397.3080 67.9477
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 6 9.000000 488.8800 54.3200
SPL-92508-GROUP SPL SESSION PER CHILD 2 12.500000 165.0000 13.2000
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 8 468.000000 240.9000 0.5147
Subtotal (Total Children Is Unduplicated) 799 4805.682580 292185.9280 60.8001
-----------------------------------------------------------------------------------------------------------------------
Total 6730.736380 419814.2980 62.3727
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 1337
-----------------------------------------------------------------------------------------------------------------------
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 24 51.000000 2710.9200 2710.9200
D 32 42.500000 2322.5000 0.0000
S 0 0.000000 0.0000 0.0000
H 18 22.500000 1500.0000 0.0000
T 0 0.000000 0.0000 0.0000
372 441.500000 45386.3300 0.0000
Other 106 152.500000 10666.5800 0.0000
---------------------------------------------------------
Total 552 710.000000 62586.3300 2710.9200
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 0 0.000000 0.0000 0.0000
12 17.000000 1104.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 12 17.000000 1104.0000 0.0000
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
92 138.250000 9920.9500 0.0000
Other 70 70.000000 1046.1100 0.0000
---------------------------------------------------------
Total 162 208.250000 10967.0600 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 12 39.000000 2412.4400 1144.8300
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 3 8.500000 451.8200 351.8200
T 0 0.000000 0.0000 0.0000
69 65.000000 7341.0000 0.0000
Other 47 96.000000 6064.0200 5139.9000
---------------------------------------------------------
Total 131 208.500000 16269.2800 6636.5500
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 19 63.250000 3323.4200 3323.4200
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
144 465.250000 25073.5000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 163 528.500000 28396.9200 3323.4200
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 70 170.000000 10895.9200 12020.3000
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
744 1235.000000 84726.6800 48.8800
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 814 1405.000000 95622.6000 12069.1800
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
605 1178.250000 74210.3400 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 605 1178.250000 74210.3400 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 6 35.000000 1821.5200 1821.5200
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 0 0.000000 0.0000 0.0000
42 103.000000 6696.2000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 48 138.000000 8517.7200 1821.5200
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 5 0.660000 33.0000 33.0000
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 2 2.000000 100.0000 100.0000
T 1 1.000000 50.0000 50.0000
460 464.526476 24944.8739 0.0000
Other 30 30.500000 1533.2500 0.0000
---------------------------------------------------------
Total 498 498.686476 26661.1239 183.0000
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 6 5.556400 322.9800 438.9900
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
608 879.012100 34256.8041 0.0000
Other 59 65.500000 3508.8800 0.0000
---------------------------------------------------------
Total 673 950.068500 38088.6641 438.9900
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 15 15.322668 1106.4800 1313.1400
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 5 7.500000 562.5000 0.0000
T 3 3.000000 203.6400 203.6400
523 500.262850 31608.8800 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 546 526.085518 33481.5000 1516.7800
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 4 6.645886 431.7400 431.7400
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 20.500000 1176.9800 1176.9800
173 335.250000 22300.0400 21004.7900
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 183 362.395886 23908.7600 22613.5100