CMS/EIP Fiscal Report Statewide
Services beginning 10/01/2012 ending 12/31/2012 Date of Report:02/16/2013 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 4340 5339.250000 197385.7500 36.9688
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 2273 2526.000000 0.0000 0.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 2966 2854.000000 105514.7500 36.9708
TCM-T1017TL-TARGETED CASE MANAGEMENT 10270 31061.25000 1148239.2500 36.9669
TCON-TCON-TRANSITION CONFERENCE 404 405.000000 0.0000 0.0000
Subtotal (Total Children Is Unduplicated) 11179 42185.50000 1451139.7500 34.3990
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Screening, Eval, and Assessment,Class #02
ASTE-ASTE-ASSISTIVE TECHNOLOGY EVAL 8 8.000000 388.0000 48.5000
AUDE-92552-PURE TONE AUDIOMETRY -AIR ONLY 48 49.000000 639.4500 13.0500
AUDE-92553-PURE TONE AUDIOMETRY AIR & BONE 4 5.000000 67.1200 13.4240
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 101 104.000000 947.4400 9.1100
AUDE-92557-COMP AUDIO THRESHOLD EVAL/SPCH RECOG 1 1.000000 23.4500 23.4500
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 75 78.000000 728.5200 9.3400
AUDE-92568-ACOUSTIC REFLEX TESTING (MEMR) 1 1.000000 7.9300 7.9300
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 109 113.000000 2433.7600 21.5377
AUDE-92585-AUD EVOKED RESPONSE (DIAG) 1 1.000000 56.9400 56.9400
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 44 46.000000 1125.6200 24.4700
AUDE-V5010-ASSESSMENT FOR HEARING AID 2 2.000000 90.0000 45.0000
AUDE-V5090-DISPENSING FEE PER HEARING AID 4 8.000000 920.0000 115.0000
EVAL-EVAL-DEVELOPMENTAL EVALUATION 82 89.500000 4475.0000 50.0000
EXIT-EXIT-EXIT ASSESSMENT 370 588.750000 29437.5000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 120 201.000000 15075.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 50 82.000000 6150.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 27 44.000000 3300.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 60 101.000000 7575.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 142 239.000000 13264.5000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 1224 1922.000000 144131.2500 74.9902
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 586 987.000000 74025.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 437 631.000000 47306.2500 74.9703
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 1881 2996.500000 166305.7500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 736 967.500000 72562.5000 75.0000
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 186 186.000000 18311.9600 98.4514
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 23 23.000000 1486.0800 64.6122
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 17 18.000000 826.6800 45.9267
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 149 150.000000 7211.7700 48.0785
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 12 12.000000 582.0000 48.5000
PSTH-97001-EVAL BY LICENSED PT, INITIAL 64 64.000000 3104.0000 48.5000
SCREEN-T1023-SCREENING 3 3.000000 150.0000 50.0000
SPCH-92506-SPEECH EVAL BY LICENSED SLP 173 179.000000 8606.0000 48.0782
Subtotal (Total Children Is Unduplicated) 3368 9900.250000 631314.4700 63.7675
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 24 136.000000 10232.0800 75.2359
AUD-HA_FUP-AUDIOLOGY SERVICES 1 1.000000 50.0000 50.0000
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 532 626.500000 31332.5000 50.0120
COIFP-COIFP-IFSP CONSULT, PRO, BY PHONE 45 27.250000 681.2500 25.0000
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 491 517.500000 25862.5000 49.9758
CONIP-CONIP-CONSULT, ITDS, PHONE 41 34.000000 850.0000 25.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 191 202.500000 10125.0000 50.0000
CONOP-CONOP-CONSULT, OT, PHONE 22 23.750000 593.7500 25.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 230 239.750000 11937.5000 49.7914
CONPP-CONPP-CONSULT, PT, PHONE 14 7.500000 187.5000 25.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 498 495.000000 24750.0000 50.0000
CONSP-CONSP-CONSULT, SLP, PHONE 38 19.500000 487.5000 25.0000
COUN-H2019HR-INDIVIDUAL/FAMILY THERAPY 9 11.000000 806.5200 73.3200
EIGF-EIGF_NM-EI GROUP SESSION BY NONMED PROF 4 632.000000 15800.0000 25.0000
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 122 3906.000000 97650.0000 25.0000
EIIF-96154-HEALTH AND BEHAVIOR INTERVENTION 1 9.000000 450.0000 50.0000
EIIF-EIIF_NM-EI INDIVIDUAL SESSION BY NONMED PROF 3 11.000000 550.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 4228 32482.00000 1619311.5000 49.8526
HERN-T1027SC-EI HEARING SERVICES AFTER SHINE 13 30.000000 1500.0000 50.0000
INTR-INTR-INTERPRETER 193 953.750000 41825.2800 43.8535
OCCT-97530-OT SESSION BY LICENSED OT 879 5429.500000 363104.6100 66.8763
OCCT-97530HM-OT SESSION BY OT ASST 43 207.000000 11015.4000 53.2145
PHY-97110-PT SESSION BY LICENSED PT 1074 5895.250007 391809.8000 66.4619
PHY-97110HM-PT SESSION BY PT ASST 56 229.250000 12426.4200 54.2047
SENS-HA_EIP-ONE UNIT UP TO $500 PER AID 4 8.000000 4000.0000 500.0000
SENS-V5264-EARMOLD 3 6.000000 108.0000 18.0000
SHIN-T1027SC-INITIAL SHINE SERVICES, INDIVIDUAL 7 8.000000 400.0000 50.0000
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 1666 10137.98650 675666.6929 66.6470
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 25 90.000000 4888.8000 54.3200
SPL-92508-GROUP SPL SESSION PER CHILD 9 12.250000 161.7000 13.2000
TRAN-TRAN-FAMILY TRANSPORTATION 420 649.000000 3560.0000 5.4854
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 6387 1258598.000 652178.7000 0.5182
VISN-EIIF_NM-EI VISION SERVICES, IND NONMED 2 4.000000 200.0000 50.0000
Subtotal (Total Children Is Unduplicated) 7525 1321639.237 4014503.0029 3.0375
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Total 1373724.986507 6096957.2229 4.4383
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Number of Children (Unduplicated) With at Least One Service 12361
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Center 02
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 787 551.000000 20063.2500 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 1008 35509.000000 55495.8800 55495.8800
3264 35336.750000 116637.1400 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 5059 71396.750000 192196.2700 55495.8800
Center 03
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 12 7.500000 277.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 390 313.750000 14148.0000 0.0000
P 5310 60530.250000 145775.5700 145811.5700
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
13883 107194.250000 339912.4200 0.0000
Other 130 130.000000 1913.9500 0.0000
---------------------------------------------------------
Total 19725 168175.750000 502027.4400 145811.5700
Center 04
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 25 34.500000 1276.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 999 1219.500000 47168.5000 0.0000
P 6430 190339.500000 379320.6200 372475.1200
D 24 30.750000 1137.7500 249.7500
S 0 0.000000 0.0000 0.0000
H 2141 7325.000000 361215.2800 360811.3000
T 0 0.000000 0.0000 0.0000
4954 8396.000000 292625.9900 0.0000
Other 49 87.250000 5564.8900 2290.8600
---------------------------------------------------------
Total 14622 207432.500000 1088309.5300 735827.0300
Center 09
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 2 2.500000 92.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 5859 5979.000000 265543.2600 0.0000
P 15892 253880.000000 708774.1600 708774.1600
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
3011 12254.500000 415976.4400 364.7800
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 24764 272116.000000 1390386.3600 709138.9400
Center 10
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 230 131.000000 4847.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 8376 6128.750000 262764.7500 0.0000
P 6254 245588.750000 444556.0700 444488.1900
D 2 1.000000 37.0000 37.0000
S 1 0.250000 9.2500 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
7961 11144.000000 566932.9800 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 22824 262993.750000 1279147.0500 444525.1900
Center 53
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 2 2.250000 159.2500 0.0000
P 1169 1092.264000 45597.4500 45737.8000
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 2440 55870.736000 78807.8300 78766.8300
T 0 0.000000 0.0000 0.0000
908 4004.249900 49093.3033 0.0000
Other 13 13.000000 650.0000 0.0000
---------------------------------------------------------
Total 4532 60982.499900 174307.8333 124504.6300
Center 54
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 196 209.250000 11584.4100 0.0000
P 1408 955.584100 38088.7400 38330.6700
D 4 1.750000 64.7500 0.0000
S 0 0.000000 0.0000 0.0000
H 2734 69320.467300 88412.2300 88412.2300
T 0 0.000000 0.0000 0.0000
1508 5296.698600 81715.1200 0.0000
Other 14 15.250000 858.2500 0.0000
---------------------------------------------------------
Total 5864 75799.000000 220723.5000 126742.9000
Center 55
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 61 68.250000 2582.2500 0.0000
P 3763 33920.529700 134131.4700 134131.4700
D 53 63.750000 3290.7500 0.0000
S 4 3.500000 129.5000 0.0000
H 1 1.500000 112.5000 0.0000
T 2912 50670.478667 93419.8396 93419.8400
4587 3997.228240 196747.9300 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 11381 88725.236607 430414.2396 227551.3100
Center 57
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 2 1.000000 37.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 1153 1091.250000 45721.7500 0.0000
P 875 973.622300 44378.4300 44378.4300
D 8 8.750000 399.7500 0.0000
S 112 5131.000000 6318.3200 6638.3200
H 5 7.750000 495.7500 0.0000
T 2954 149035.127700 242655.7000 243225.9400
4004 9689.000000 478983.9600 309501.8900
Other 12 166.000000 454.3400 454.3400
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Total 9125 166103.500000 819445.0000 604198.9200