CMS/EIP Fiscal Report Statewide
Services beginning 07/01/2012 ending 09/30/2012 Date of Report:11/15/2012 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 6441 5377.250000 198745.5000 36.9604
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 2907 3280.000000 0.0000 0.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 4771 5223.000000 193104.0000 36.9719
TCM-T1017TL-TARGETED CASE MANAGEMENT 5707 16986.25000 627941.2500 36.9676
TCON-TCON-TRANSITION CONFERENCE 440 444.000000 0.0000 0.0000
Subtotal (Total Children Is Unduplicated) 12044 31310.50000 1019790.7500 32.5702
-----------------------------------------------------------------------------------------------------------------------
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 52 53.000000 654.9600 12.3577
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 52 52.000000 461.2700 8.8706
AUDE-92557-COMP AUDIO THRESHOLD EVAL/SPCH RECOG 1 2.000000 46.9000 23.4500
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 62 64.000000 610.0200 9.5316
AUDE-92568-ACOUSTIC REFLEX TESTING (MEMR) 1 1.000000 7.9300 7.9300
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 64 64.000000 1348.6700 21.0730
AUDE-92582-CONDITIONED PLAY AUDIOMETRY 1 1.000000 25.2600 25.2600
AUDE-92585-AUD EVOKED RESPONSE (DIAG) 1 1.000000 56.9400 56.9400
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 38 38.000000 954.3400 25.1142
AUDE-92588-OTOACOUSTIC EMISSIONS (COMP) 1 1.000000 27.2800 27.2800
EVAL-EVAL-DEVELOPMENTAL EVALUATION 96 119.000000 5950.0000 50.0000
EXIT-EXIT-TRANSITION ASSESSMENT 585 948.000000 47400.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 29 45.000000 3370.4400 74.8987
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 12 20.500000 1537.5000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 2 2.500000 187.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 39 40.500000 3037.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 49 80.000000 4428.7200 55.3590
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 394 594.411500 43958.8200 73.9535
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 110 185.785600 13933.9200 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 70 90.111067 6758.3300 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 467 787.500000 43614.7500 55.3838
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 381 502.943199 37720.7400 75.0000
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 8 8.000000 324.0000 40.5000
NUTR-97803-NUTRITIONAL EVAL, FOLLOW-UP 2 1.000000 50.0000 50.0000
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 19 19.000000 921.5000 48.5000
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 84 85.000000 4043.2900 47.5681
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 11 11.000000 533.5000 48.5000
PSTH-97001-EVAL BY LICENSED PT, INITIAL 40 41.000000 1946.0000 47.4634
SCREEN-T1023-INTERDISCIPLINARY SCREENING 41 41.000000 2050.0000 50.0000
SENS-V5014TS-HEARING AID REPAIR IN-OFFICE 2 2.000000 30.0000 15.0000
SPCH-92506-SPEECH EVAL BY LICENSED SLP 110 110.999999 5343.5000 48.1396
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) 1999 4035.251365 232495.6600 57.6162
-----------------------------------------------------------------------------------------------------------------------
EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 32 94.000000 31230.3000 332.2372
AUD-HA_FUP-AUDIOLOGY SERVICES 1 2.000000 100.0000 50.0000
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 805 966.500000 48325.0000 50.0000
COIFP-COIFP-IFSP CONSULT, PRO, BY PHONE 49 34.750000 868.7500 25.0000
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 810 1082.500000 54125.0000 50.0000
CONIP-CONIP-CONSULT, ITDS, PHONE 72 58.750000 1468.7500 25.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 261 404.250000 20212.5000 50.0000
CONOP-CONOP-CONSULT, OT, PHONE 23 32.250000 806.2500 25.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 333 411.000000 20550.0000 50.0000
CONPP-CONPP-CONSULT, PT, PHONE 19 8.750000 218.7500 25.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 745 835.250000 41756.2500 49.9925
CONSP-CONSP-CONSULT, SLP, PHONE 62 37.000000 925.0000 25.0000
COUN-H2019HR-INDIVIDUAL/FAMILY THERAPY 17 45.000000 3299.4000 73.3200
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 29 141.250000 3531.2500 25.0000
EIIF-96154-HEALTH AND BEHAVIOR INTERVENTION 41 390.250000 12225.1600 31.3265
EIIF-EIIF_NM-EI INDIVIDUAL SESSION BY NONMED PROF 1 1.000000 50.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 1915 14055.46020 702439.6400 49.9763
HERN-T1027SC-EI HEARING SERVICES AFTER SHINE 7 18.000000 900.0000 50.0000
INTR-INTR-INTERPRETER 254 1095.250000 43218.8400 39.4603
OCCT-97530-OT SESSION BY LICENSED OT 508 2666.733778 176382.1900 66.1417
OCCT-97530HM-OT SESSION BY OT ASST 28 113.250000 6108.5200 53.9384
PHY-97110-PT SESSION BY LICENSED PT 523 2615.185229 166446.3076 63.6461
PHY-97110HM-PT SESSION BY PT ASST 19 67.750000 3585.4800 52.9222
SENS-FM-FM RECEIVER HEARING AID 1 1.000000 1650.0000 1650.0000
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 20 138.750000 6937.5000 50.0000
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 1266 7537.440812 505100.9990 67.0123
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 34 137.500000 7469.0000 54.3200
TRAN-TRAN-FAMILY TRANSPORTATION 406 470.000000 3317.5000 7.0585
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 9022 1879623.000 960885.9500 0.5112
VISN-EIIF_NM-EI VISION SERVICES, IND NONMED 4 12.000000 600.0000 50.0000
VISN-T1027SC-EI VISION SERVICES, INDIVIDUAL 1 1.000000 50.0000 50.0000
CMS/EIP Fiscal Report Statewide
Services beginning 07/01/2012 ending 09/30/2012 Date of Report:11/15/2012 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
Subtotal (Total Children Is Unduplicated) 9807 1913100.820 2825276.2866 1.4768
-----------------------------------------------------------------------------------------------------------------------
Total 1948446.571384 4077562.6966 2.0927
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 15041
-----------------------------------------------------------------------------------------------------------------------
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 4210 184107.000000 207179.9700 207179.9700
D 44 31.250000 1537.7500 0.0000
S 1 0.500000 18.5000 0.0000
H 1 2.000000 100.0000 0.0000
T 2645 95488.250000 118019.7300 118019.7300
4833 6696.500000 115782.3300 0.0000
Other 274 8048.250000 16983.9400 0.0000
---------------------------------------------------------
Total 12008 294373.750000 459622.2200 325199.7000
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 1180 42130.500000 74994.7800 74994.7800
2237 26698.500000 78695.2700 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 3417 68829.000000 153690.0500 74994.7800
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 6163 114217.500000 184985.3800 184985.3800
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
9976 57916.750000 223941.2600 0.0000
Other 13 12.250000 247.7600 0.0000
---------------------------------------------------------
Total 16152 172146.500000 409174.4000 184985.3800
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 3590 171412.500000 239742.1200 233770.0800
D 107 118.000000 4366.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 15 543.000000 1463.6400 713.6400
T 0 0.000000 0.0000 0.0000
3497 3120.250000 94099.7700 0.0000
Other 12 45.000000 1632.4800 1632.4800
---------------------------------------------------------
Total 7221 175238.750000 341304.0100 236116.2000
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 3178 153739.750000 235293.3600 235293.3600
D 1 0.750000 27.7500 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
6162 9651.750000 142421.7500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 9341 163392.250000 377742.8600 235293.3600
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 15500 235624.250000 688197.2800 688197.2800
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
292 8096.000000 20461.0900 15.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 15792 243720.250000 708658.3700 688212.2800
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 6032 225086.500000 424329.7100 424329.7100
D 16 8.750000 323.7500 323.7500
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
6018 4374.500000 163305.5000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 12066 229469.750000 587958.9600 424653.4600
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 637 31654.750000 51534.8800 51602.7600
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
656 5072.000000 19247.2300 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 1298 36730.000000 70902.3600 51602.7600
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 0 0.000000 0.0000 0.0000
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 749 36924.053624 35257.0300 35257.0300
T 2363 52578.250000 66855.0900 66761.5900
4360 77179.258600 130131.0890 110.5000
Other 9 9.000000 450.0000 0.0000
---------------------------------------------------------
Total 7481 166690.562224 232693.2090 102129.1200
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 0 0.000000 0.0000 0.0000
D 0 0.000000 0.0000 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
4042 64416.836800 102579.2500 0.0000
Other 1 0.500000 18.5000 0.0000
---------------------------------------------------------
Total 8078 174892.685300 230895.3400 128191.0900
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 3246 54580.899650 101403.3100 101403.3100
D 57 61.250000 2893.2500 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 1554 26453.449300 50549.2476 50549.2500
1871 1552.120799 40864.8900 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 6728 82647.719749 195710.6976 151952.5600
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 20 22.250000 1143.2500 0.0000
S 120 2843.500000 7240.9600 7280.9600
H 0 0.000000 0.0000 0.0000
T 2820 135786.604111 229053.1100 229029.7900
1864 1663.000000 71772.9000 100.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 4824 140315.354111 309210.2200 236410.7500