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
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 6444 5383.500000 198976.7500 36.9605
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 2908 3281.000000 0.0000 0.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 4774 5227.250000 193261.2500 36.9719
TCM-T1017TL-TARGETED CASE MANAGEMENT 15943 50721.75000 1874253.2500 36.9517
TCON-TCON-TRANSITION CONFERENCE 441 445.000000 0.0000 0.0000
Subtotal (Total Children Is Unduplicated) 16402 65058.50000 2266491.2500 34.8377
-----------------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
ASTE-ASTE-ASSISTIVE TECHNOLOGY EVAL 17 17.000000 824.5000 48.5000
AUD-92626-EVAL OF AUD REHAB STATUS 1 1.000000 39.0800 39.0800
AUDE-92552-PURE TONE AUDIOMETRY -AIR ONLY 53 57.000000 685.5800 12.0277
AUDE-92553-PURE TONE AUDIOMETRY AIR & BONE 1 1.000000 16.7800 16.7800
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 131 133.000000 1177.6000 8.8541
AUDE-92557-COMP AUDIO THRESHOLD EVAL/SPCH RECOG 1 2.000000 46.9000 23.4500
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 99 104.000000 990.1000 9.5202
AUDE-92568-ACOUSTIC REFLEX TESTING (MEMR) 1 1.000000 7.9300 7.9300
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 140 144.000000 3057.0600 21.2296
AUDE-92582-CONDITIONED PLAY AUDIOMETRY 1 1.000000 25.2600 25.2600
AUDE-92585-AUD EVOKED RESPONSE (DIAG) 2 2.000000 113.8800 56.9400
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 43 43.000000 1079.4100 25.1026
AUDE-92588-OTOACOUSTIC EMISSIONS (COMP) 1 1.000000 27.2800 27.2800
AUDE-V5090-DISPENSING FEE PER HEARING AID 1 2.000000 230.0000 115.0000
EVAL-EVAL-DEVELOPMENTAL EVALUATION 98 122.500000 6125.0000 50.0000
EXIT-EXIT-TRANSITION ASSESSMENT 586 949.000000 47450.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 191 324.000000 24300.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 57 90.500000 6787.5000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 39 53.000000 3975.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 108 165.000000 12375.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 245 407.000000 22608.0000 55.5479
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 1618 2577.000000 192615.4700 74.7441
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 667 1112.000000 83362.5000 74.9663
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 472 657.500000 49312.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 2319 3748.000000 207922.5000 55.4756
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 1180 1898.500000 142348.5000 74.9795
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 184 184.000000 15886.6100 86.3403
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 35 35.000000 1434.4800 40.9851
MED-99214-OUTPATIENT VISIT, EST, 25 MINS 1 1.000000 48.2700 48.2700
NUTR-97803-NUTRITIONAL EVAL, FOLLOW-UP 2 1.000000 50.0000 50.0000
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 37 37.000000 1794.5000 48.5000
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 134 139.000000 6638.7900 47.7611
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 23 23.000000 1115.5000 48.5000
PSTH-97001-EVAL BY LICENSED PT, INITIAL 99 101.000000 4856.0000 48.0792
SCREEN-T1023-INTERDISCIPLINARY SCREENING 111 111.000000 5550.0000 50.0000
SENS-V5014TS-HEARING AID REPAIR IN-OFFICE 2 2.000000 30.0000 15.0000
SPCH-92506-SPEECH EVAL BY LICENSED SLP 231 233.999998 11309.0000 48.3291
VISF-VISF-VISION EVALUATION FUNCTIONAL 1 4.000000 250.0000 62.5000
WHEELP-97001TG-WHEELCHAIR EVAL/ FITTING BY LICENSED P 1 1.000000 48.5000 48.5000
Subtotal (Total Children Is Unduplicated) 4652 13486.00000 856514.9800 63.5114
-----------------------------------------------------------------------------------------------------------------------
EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 47 164.000000 63019.8200 384.2672
AUD-HA_FUP-AUDIOLOGY SERVICES 1 2.000000 100.0000 50.0000
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 808 970.500000 48525.0000 50.0000
COIFP-COIFP-IFSP CONSULT, PRO, BY PHONE 49 34.750000 868.7500 25.0000
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 819 1093.000000 54650.0000 50.0000
CONIP-CONIP-CONSULT, ITDS, PHONE 72 58.750000 1468.7500 25.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 263 406.250000 20312.5000 50.0000
CONOP-CONOP-CONSULT, OT, PHONE 23 32.250000 806.2500 25.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 336 414.000000 20700.0000 50.0000
CONPP-CONPP-CONSULT, PT, PHONE 21 9.750000 243.7500 25.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 747 836.750000 41831.2500 49.9925
CONSP-CONSP-CONSULT, SLP, PHONE 66 41.000000 1025.0000 25.0000
COUN-H2019HR-INDIVIDUAL/FAMILY THERAPY 17 45.000000 3299.4000 73.3200
EIGF-EIGF_NM-EI GROUP SESSION BY NONMED PROF 7 644.000000 16100.0000 25.0000
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 150 2685.250000 67131.2500 25.0000
EIIF-96154-HEALTH AND BEHAVIOR INTERVENTION 53 536.750000 19553.7700 36.4299
EIIF-EIIF_NM-EI INDIVIDUAL SESSION BY NONMED PROF 1 1.000000 50.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 5900 44129.00000 2206154.2600 49.9933
HERN-T1027SC-EI HEARING SERVICES AFTER SHINE 27 67.750000 3387.5000 50.0000
INTR-INTR-INTERPRETER 254 1095.250000 43218.8400 39.4603
OCCT-97530-OT SESSION BY LICENSED OT 919 4999.000000 334390.2700 66.8914
OCCT-97530HM-OT SESSION BY OT ASST 41 186.000000 10055.9800 54.0644
PHY-97110-PT SESSION BY LICENSED PT 1153 6132.058200 404855.8076 66.0228
PHY-97110HM-PT SESSION BY PT ASST 58 228.500000 12335.7000 53.9856
SENS-FM-FM RECEIVER HEARING AID 1 1.000000 1650.0000 1650.0000
SENS-HA_EIP-ONE UNIT UP TO $500 PER AID 1 2.000000 1000.0000 500.0000
SENS-V5050-MED HEARING AID - ANALOG/DIGITAL 1 2.000000 456.0000 228.0000
SENS-V5264-EARMOLD 1 2.000000 36.0000 18.0000
SHIN-T1027SC-INITIAL SHINE SERVICES, INDIVIDUAL 31 171.750000 8587.5000 50.0000
CMS/EIP Fiscal Report Statewide
Services beginning 07/01/2012 ending 09/30/2012 Date of Report:11/16/2012 Page: 2
List order: No List
Eligibility Filter:Program Patients
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 2091 12209.80910 822257.0470 67.3440
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 38 153.000000 8310.9600 54.3200
SPL-92508-GROUP SPL SESSION PER CHILD 5 14.500000 191.4000 13.2000
TRAN-TRAN-FAMILY TRANSPORTATION 406 470.000000 3317.5000 7.0585
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 9028 1881913.000 962039.3500 0.5112
VISN-EIIF_NM-EI VISION SERVICES, IND NONMED 25 379.000000 18950.0000 50.0000
VISN-T1027SC-EI VISION SERVICES, INDIVIDUAL 5 8.500000 425.0000 50.0000
Subtotal (Total Children Is Unduplicated) 10186 1960139.117 5201304.6046 2.6535
-----------------------------------------------------------------------------------------------------------------------
Total 2038683.617297 8324310.8346 4.0832
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 17583
-----------------------------------------------------------------------------------------------------------------------
Center 01
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 3371 2343.000000 93087.2500 0.0000
P 5935 185422.750000 258052.8900 259884.3900
D 172 151.500000 6777.7500 0.0000
S 159 107.500000 4129.5000 0.0000
H 25 32.500000 2175.0000 0.0000
T 2645 95488.250000 118019.7300 118019.7300
6576 10608.000000 344577.8100 0.0000
Other 595 8569.250000 52785.5200 0.0000
---------------------------------------------------------
Total 19478 302722.750000 879605.4500 377904.1200
Center 02
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 1185 1000.000000 36546.7500 0.0000
P 1 0.750000 27.7500 0.0000
D 0 0.000000 0.0000 0.0000
S 1 1.000000 37.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 1180 42130.500000 74994.7800 74994.7800
2606 27119.500000 102935.0200 0.0000
Other 1 0.500000 18.5000 0.0000
---------------------------------------------------------
Total 4974 70252.250000 214559.8000 74994.7800
Center 03
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 54 47.750000 2670.7500 0.0000
U 0 0.000000 0.0000 0.0000
B 324 278.000000 12197.2500 0.0000
P 9564 116429.250000 272658.6300 272621.1300
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
10108 58119.250000 242289.0500 0.0000
Other 211 210.500000 3204.8300 0.0000
---------------------------------------------------------
Total 20261 175084.750000 533020.5100 272621.1300
Center 04
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 1444 1836.000000 68052.7500 0.0000
P 6794 175071.250000 383178.5700 375644.6300
D 107 118.000000 4366.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 2128 7370.000000 347310.5800 328671.1800
T 0 0.000000 0.0000 0.0000
4688 7152.500000 239851.5800 0.0000
Other 63 144.500000 7826.0000 6772.3800
---------------------------------------------------------
Total 15224 191692.250000 1050585.4800 711088.1900
Center 07
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 14 6.500000 244.2500 0.0000
U 0 0.000000 0.0000 0.0000
B 430 296.750000 11092.7500 0.0000
P 6907 156490.250000 349206.0300 349206.0300
D 1 0.750000 27.7500 0.0000
S 1 0.500000 18.5000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
7566 13579.000000 345759.5000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 14919 170373.750000 706348.7800 349206.0300
Center 09
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 5855 5772.000000 257189.2200 0.0000
P 15577 235819.250000 700736.5600 701860.9400
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
3151 15361.750000 423728.1500 63.8800
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 24583 256953.000000 1381653.9300 701924.8200
Center 10
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 56 26.750000 989.7500 0.0000
U 0 0.000000 0.0000 0.0000
B 6097 4534.750000 190672.7500 0.0000
P 8942 227276.500000 518398.9600 518198.9600
D 16 8.750000 323.7500 323.7500
S 40 27.500000 1017.5000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
8435 10735.750000 522437.4400 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 23586 242610.000000 1233840.1500 518522.7100
Center 51
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 790 591.500000 23486.5000 0.0000
P 644 31692.000000 53439.6500 53424.2800
D 5 3.250000 120.2500 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
1009 6168.750000 85256.3800 0.0000
Other 5 7.000000 475.1600 0.0000
---------------------------------------------------------
Total 2453 38462.500000 162777.9400 53424.2800
Center 53
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 1 1.500000 55.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 289 251.500000 10736.7500 9.2500
P 2982 2839.160000 117895.5000 117827.0000
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 751 36926.053624 35357.0300 35357.0300
T 2364 52579.250000 66905.0900 66811.5900
6732 79616.785076 260382.4929 110.5000
Other 39 39.500000 1983.2500 0.0000
---------------------------------------------------------
Total 13158 172253.748700 493315.6129 220115.3700
Center 54
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 742 677.000000 35038.9200 0.0000
P 4313 2928.306400 118280.7300 118396.7400
D 3 1.250000 46.2500 0.0000
S 2 2.000000 37.0000 0.0000
H 1400 52636.429600 49366.5400 49366.5400
T 2633 57836.918900 78894.0500 78824.5500
7304 69041.713600 281096.1441 0.0000
Other 88 89.000000 4784.1300 0.0000
---------------------------------------------------------
Total 16485 183212.618500 567543.7641 246587.8300
Center 55
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 16 13.000000 481.0000 0.0000
P 4993 56347.047251 170918.6600 171162.8200
D 57 61.250000 2893.2500 0.0000
S 39 20.500000 712.2500 0.0000
H 5 7.500000 562.5000 0.0000
T 1557 26456.449300 50752.8876 50752.8900
4843 4247.253549 206485.5900 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 11510 87153.000100 432806.1376 221915.7100
Center 57
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 58 42.750000 1581.7500 0.0000
U 0 0.000000 0.0000 0.0000
B 1422 1314.000000 49960.7500 0.0000
P 593 649.395886 34928.7400 34928.7400
D 20 22.250000 1143.2500 0.0000
S 120 2843.500000 7240.9600 7280.9600
H 1 1.500000 112.5000 0.0000
T 2827 135810.104111 230433.7300 230410.4100
3499 6874.000000 341924.3200 238493.6800
Other 23 355.500000 927.2800 927.2800
---------------------------------------------------------
Total 8563 147912.999997 668253.2800 512041.0700