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:TPIN
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 2 0.750000 27.7500 37.0000
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 1 1.000000 0.0000 0.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 2 2.000000 74.0000 37.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 18 35.750000 1322.7500 37.0000
Subtotal (Total Children Is Unduplicated) 19 39.500000 1424.5000 36.0633
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Screening, Eval, and Assessment,Class #02
AUDE-92552-PURE TONE AUDIOMETRY -AIR ONLY 1 1.000000 13.0500 13.0500
AUDE-92553-PURE TONE AUDIOMETRY AIR & BONE 1 1.000000 0.9900 0.9900
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 19 20.000000 182.2000 9.1100
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 9 9.000000 84.0600 9.3400
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 23 24.000000 503.9500 20.9979
AUDE-V5090-DISPENSING FEE PER HEARING AID 1 2.000000 230.0000 115.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 34 62.000000 4650.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 12 22.000000 1650.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 7 13.000000 975.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 19 34.500000 2587.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 29 49.500000 2747.2500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 278 488.789600 36659.2200 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 129 225.970667 16947.8000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 100 172.500000 12937.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 321 558.500000 30996.7500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 139 197.311300 14798.3500 75.0000
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 39 39.000000 10920.0000 280.0000
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 5 5.000000 900.0000 180.0000
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 16 15.813000 766.4300 48.4683
PSTH-97001-EVAL BY LICENSED PT, INITIAL 8 8.000000 388.0000 48.5000
SPCH-92506-SPEECH EVAL BY LICENSED SLP 24 23.891800 1125.2500 47.0977
Subtotal (Total Children Is Unduplicated) 647 1972.776367 140063.3000 70.9981
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 12 70.000000 5158.1500 73.6879
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 1 20.000000 1000.0000 50.0000
EIIF-EIIF_NM-EI INDIVIDUAL SESSION BY NONMED PROF 1 1.000000 50.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 71 317.947800 15897.3900 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 112 441.815414 29643.1300 67.0939
OCCT-97530HM-OT SESSION BY OT ASST 5 31.000000 1599.4000 51.5935
PHY-97110-PT SESSION BY LICENSED PT 199 823.615984 55138.0200 66.9463
PHY-97110HM-PT SESSION BY PT ASST 8 20.704900 1124.6900 54.3200
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 257 1070.557819 72413.5343 67.6409
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 2 3.000000 162.9600 54.3200
SPL-92508-GROUP SPL SESSION PER CHILD 1 3.000000 39.6000 13.2000
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 2 82.000000 41.0000 0.5000
Subtotal (Total Children Is Unduplicated) 543 2884.641917 182267.8743 63.1856
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Total 4896.918284 323755.6743 66.1142
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Number of Children (Unduplicated) With at Least One Service 1126
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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 1 1.000000 50.0000 50.0000
19 24.500000 1356.5000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 20 25.500000 1406.5000 50.0000
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
110 182.000000 11656.8900 0.0000
Other 48 48.000000 704.1400 0.0000
---------------------------------------------------------
Total 158 230.000000 12361.0300 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 40 132.000000 7363.9600 3760.6800
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 3 3.000000 185.7600 185.7600
T 0 0.000000 0.0000 0.0000
138 125.000000 16480.7500 0.0000
Other 34 59.500000 3865.1600 1629.9400
---------------------------------------------------------
Total 215 319.500000 27895.6300 5576.3800
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 63 149.000000 9187.6800 9187.6800
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
902 1541.750000 105311.4900 131.2000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 965 1690.750000 114499.1700 9318.8800
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
772 1387.250000 93136.7000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 772 1387.250000 93136.7000 0.0000
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 7 5.264000 263.2000 403.5500
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 1 1.000000 50.0000 50.0000
T 0 0.000000 0.0000 0.0000
90 181.422200 5452.4143 0.0000
Other 13 13.000000 650.0000 0.0000
---------------------------------------------------------
Total 111 200.686200 6415.6143 453.5500
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 15 10.584100 561.9900 803.9200
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
144 159.851800 10007.7300 0.0000
Other 14 15.250000 858.2500 0.0000
---------------------------------------------------------
Total 173 185.685900 11427.9700 803.9200
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 0 0.000000 0.0000 0.0000
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 1 1.500000 112.5000 0.0000
T 0 0.000000 0.0000 0.0000
592 485.173884 31913.4400 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 593 486.673884 32025.9400 0.0000
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 2 1.122300 54.4300 54.4300
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 7 11.000000 545.5000 545.5000
183 358.750000 23987.1900 23396.9100
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 192 370.872300 24587.1200 23996.8400