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
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 4340 5338.500000 197358.0000 36.9688
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 2272 2525.000000 0.0000 0.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 2965 2852.000000 105440.7500 36.9708
TCM-T1017TL-TARGETED CASE MANAGEMENT 3310 10221.00000 377779.2500 36.9611
TCON-TCON-TRANSITION CONFERENCE 404 405.000000 0.0000 0.0000
Subtotal (Total Children Is Unduplicated) 8148 21341.50000 680578.0000 31.8899
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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 46 47.000000 613.3500 13.0500
AUDE-92553-PURE TONE AUDIOMETRY AIR & BONE 4 4.000000 66.1300 16.5325
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 48 50.000000 455.5000 9.1100
AUDE-92557-COMP AUDIO THRESHOLD EVAL/SPCH RECOG 1 1.000000 23.4500 23.4500
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 52 55.000000 513.7000 9.3400
AUDE-92568-ACOUSTIC REFLEX TESTING (MEMR) 1 1.000000 7.9300 7.9300
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 52 54.000000 1169.2600 21.6530
AUDE-92585-AUD EVOKED RESPONSE (DIAG) 1 1.000000 56.9400 56.9400
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 42 44.000000 1076.6800 24.4700
AUDE-V5010-ASSESSMENT FOR HEARING AID 2 2.000000 90.0000 45.0000
AUDE-V5090-DISPENSING FEE PER HEARING AID 3 6.000000 690.0000 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 23 34.500000 2587.5000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 2 3.500000 262.5000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 5 6.500000 487.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 15 16.500000 1237.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 21 36.000000 1998.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 304 441.563200 33098.4900 74.9575
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 119 195.529333 14664.7000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 70 82.000000 6131.2500 74.7713
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 435 702.500000 38988.7500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 257 265.188700 19889.1500 75.0000
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 7 7.000000 303.7600 43.3943
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 7 7.000000 293.1800 41.8829
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 97 96.187000 4602.3400 47.8478
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 4 4.000000 194.0000 48.5000
PSTH-97001-EVAL BY LICENSED PT, INITIAL 28 28.000000 1358.0000 48.5000
SCREEN-T1023-SCREENING 2 2.000000 100.0000 50.0000
SPCH-92506-SPEECH EVAL BY LICENSED SLP 104 103.108200 4958.7500 48.0927
Subtotal (Total Children Is Unduplicated) 1483 2982.326433 170218.8100 57.0758
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 19 66.000000 5073.9300 76.8777
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 489 497.000000 24837.5000 49.9748
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 497 494.000000 24700.0000 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-T1027TTSC-EI GROUP SESSION BY EI PROF 13 55.000000 1375.0000 25.0000
EIIF-96154-HEALTH AND BEHAVIOR INTERVENTION 1 9.000000 450.0000 50.0000
EIIF-EIIF_NM-EI INDIVIDUAL SESSION BY NONMED PROF 2 4.000000 200.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 1360 10724.69060 531496.0300 49.5582
HERN-T1027SC-EI HEARING SERVICES AFTER SHINE 4 18.000000 900.0000 50.0000
INTR-INTR-INTERPRETER 193 953.750000 41825.2800 43.8535
OCCT-97530-OT SESSION BY LICENSED OT 441 2735.520386 180703.3600 66.0581
OCCT-97530HM-OT SESSION BY OT ASST 27 113.500000 6021.0000 53.0485
PHY-97110-PT SESSION BY LICENSED PT 412 2376.998423 153759.9100 64.6866
PHY-97110HM-PT SESSION BY PT ASST 19 45.045100 2420.4100 53.7330
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 2 2.000000 100.0000 50.0000
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 911 5801.178681 381649.4686 65.7883
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 20 80.500000 4372.7600 54.3200
SPL-92508-GROUP SPL SESSION PER CHILD 2 2.000000 26.4000 13.2000
TRAN-TRAN-FAMILY TRANSPORTATION 420 649.000000 3560.0000 5.4854
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 6385 1258336.000 652047.7000 0.5182
VISN-EIIF_NM-EI VISION SERVICES, IND NONMED 2 4.000000 200.0000 50.0000
Subtotal (Total Children Is Unduplicated) 7022 1284173.933 2076878.2686 1.6173
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Total 1308497.759623 2927675.0786 2.2374
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Number of Children (Unduplicated) With at Least One Service 10639
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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 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 1007 35508.000000 55445.8800 55445.8800
2868 34874.250000 90886.8900 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 3875 70382.250000 146332.7700 55445.8800
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 3150 59232.500000 91792.0700 91792.0700
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
13770 107007.750000 327918.0300 0.0000
Other 1 1.000000 24.4700 0.0000
---------------------------------------------------------
Total 16921 166241.250000 419734.5700 91792.0700
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 3889 187325.000000 262206.4000 259237.3200
D 23 30.250000 1119.2500 249.7500
S 0 0.000000 0.0000 0.0000
H 6 186.000000 407.8800 407.8800
T 0 0.000000 0.0000 0.0000
3555 3198.250000 96356.5100 0.0000
Other 9 18.000000 1202.4600 339.4000
---------------------------------------------------------
Total 7482 190757.500000 361292.5000 260234.3500
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 15826 253727.750000 699466.2300 699466.2300
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
295 5435.000000 17893.5800 233.5800
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 16121 259162.750000 717359.8100 699699.8100
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 6241 245566.750000 443059.4400 443059.4400
D 2 1.000000 37.0000 37.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
5085 3812.000000 145475.2500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 11328 249379.750000 588571.6900 443096.4400
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 2439 55869.736000 78757.8300 78716.8300
T 0 0.000000 0.0000 0.0000
117 3101.327700 4735.5390 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 2556 58971.063700 83493.3690 78716.8300
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 3 1.250000 46.2500 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
109 3910.538200 4729.4800 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 2846 73232.255500 93187.9600 88412.2300
Center 55
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 2 1.500000 55.5000 0.0000
P 1824 32043.529700 60781.2200 60781.2200
D 53 63.750000 3290.7500 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 2912 50670.478667 93419.8396 93419.8400
1812 1485.554356 36687.5000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 6603 84264.812723 194234.8096 154201.0600
Center 57
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 1 1.000000 37.0000 0.0000
P 1 1.250000 46.2500 46.2500
D 8 8.750000 399.7500 0.0000
S 110 5110.000000 6258.3200 6578.3200
H 0 0.000000 0.0000 0.0000
T 2944 149015.127700 241660.2000 242230.4400
1822 1970.000000 75066.0800 622.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 4886 156106.127700 323467.6000 249477.0100