CMS/EIP Fiscal Report Statewide
Services beginning 01/01/2013 ending 03/31/2013 Date of Report:05/17/2013 Page: 1
List order: No List
Payclass Filters:MED
Eligibility Filter:Part C (excluding not eligible)
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 5347 15912.00000 588244.5000 36.9686
Subtotal (Total Children Is Unduplicated) 5347 15912.00000 588244.5000 36.9686
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Screening, Eval, and Assessment,Class #02
AUDE-92552-PURE TONE AUDIOMETRY -AIR ONLY 3 3.000000 39.1500 13.0500
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 46 46.000000 419.0600 9.1100
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 18 18.000000 168.1200 9.3400
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 43 43.000000 934.3900 21.7300
AUDE-92585-AUD EVOKED RESPONSE (DIAG) 1 1.000000 56.9400 56.9400
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 3 3.000000 73.4100 24.4700
AUDE-92588-OTOACOUSTIC EMISSIONS (COMP) 2 2.000000 54.5600 27.2800
AUDE-V5090-DISPENSING FEE PER HEARING AID 1 2.000000 230.0000 115.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 58 95.000000 7125.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 18 29.000000 2175.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 25 27.000000 2025.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 31 56.000000 4200.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 79 116.500000 6465.7500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 441 680.500000 51037.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 173 279.500000 20962.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 212 273.500000 20512.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 745 1108.500000 61521.7500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 236 325.000000 24375.0000 75.0000
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 113 113.000000 5721.1900 50.6300
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 19 19.000000 618.6400 32.5600
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 13 14.000000 679.0000 48.5000
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 48 48.000000 2328.0000 48.5000
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 7 7.000000 339.5000 48.5000
PSTH-97001-EVAL BY LICENSED PT, INITIAL 32 33.000000 1600.5000 48.5000
SPCH-92506-SPEECH EVAL BY LICENSED SLP 48 48.000000 2328.0000 48.5000
Subtotal (Total Children Is Unduplicated) 1212 3390.500000 215990.4600 63.7046
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 2407 20072.25000 1003612.5000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 308 1666.750000 113138.9900 67.8800
OCCT-97530HM-OT SESSION BY OT ASST 16 51.250000 2783.9000 54.3200
PHY-97110-PT SESSION BY LICENSED PT 369 2078.500000 141088.5800 67.8800
PHY-97110HM-PT SESSION BY PT ASST 43 226.000000 12276.3200 54.3200
SENS-V5050-MED HEARING AID - ANALOG/DIGITAL 1 2.000000 456.0000 228.0000
SENS-V5264-EARMOLD 1 2.000000 36.0000 18.0000
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 449 2531.250000 171821.2500 67.8800
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 2 8.500000 461.7200 54.3200
SPL-92508-GROUP SPL SESSION PER CHILD 25 45.250000 597.3000 13.2000
Subtotal (Total Children Is Unduplicated) 3071 26683.75000 1446272.5600 54.2005
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Total 45986.250000 2250507.5200 48.9387
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Number of Children (Unduplicated) With at Least One Service 6024
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Center 02
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 2 0.500000 18.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 982 614.500000 22422.0000 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
97 178.250000 12307.2500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 1081 793.250000 34747.7500 0.0000
Center 03
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 3 2.750000 101.7500 0.0000
U 0 0.000000 0.0000 0.0000
B 411 329.750000 14328.5000 50.0000
P 1608 988.750000 40084.7500 40110.7500
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
3 3.250000 209.2500 0.0000
Other 105 105.000000 1584.3200 0.0000
---------------------------------------------------------
Total 2130 1429.500000 56308.5700 40160.7500
Center 04
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 112 62.500000 2312.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 1818 1897.250000 72881.2500 0.0000
P 1416 1735.000000 66813.6700 66779.3200
D 1 1.250000 46.2500 0.0000
S 0 0.000000 0.0000 0.0000
H 2320 7477.500000 378441.5400 348018.1600
T 0 0.000000 0.0000 0.0000
550 719.000000 42746.9500 0.0000
Other 3 2.250000 83.2500 0.0000
---------------------------------------------------------
Total 6220 11894.750000 563325.4100 414797.4800
Center 09
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 5 4.750000 175.7500 0.0000
U 0 0.000000 0.0000 0.0000
B 5087 5015.500000 219463.5800 0.0000
P 282 288.500000 13701.7500 13701.7500
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
1869 5455.500000 301133.5200 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 7243 10764.250000 534474.6000 13701.7500
Center 10
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 323 176.250000 6521.2500 0.0000
U 0 0.000000 0.0000 0.0000
B 2501 1524.250000 56397.2500 0.0000
P 3624 2794.500000 128768.8800 128401.0000
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
2165 6059.750000 329580.9600 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 8613 10554.750000 521268.3400 128401.0000
Center 55
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 4 2.500000 92.5000 0.0000
P 1876 1698.250000 65309.2500 65309.2500
D 0 0.000000 0.0000 0.0000
S 2 2.000000 131.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
2066 1830.500000 115554.0300 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 3948 3533.250000 181086.7800 65309.2500
Center 57
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 178 153.000000 5661.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 1165 1070.000000 42309.7500 0.0000
P 404 471.000000 25606.7500 25493.3000
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 4 4.000000 280.5000 280.5000
1600 5318.500000 285438.0700 284878.5700
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 3351 7016.500000 359296.0700 310652.3700