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
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 4474 6565.000000 242591.5000 36.9522
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 2329 2567.000000 0.0000 0.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 2508 2295.000000 84823.5000 36.9601
TCM-T1017TL-TARGETED CASE MANAGEMENT 8733 27739.75000 1025631.7500 36.9734
TCON-TCON-TRANSITION CONFERENCE 364 367.000000 0.0000 0.0000
Subtotal (Total Children Is Unduplicated) 9729 39533.75000 1353046.7500 34.2251
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Screening, Eval, and Assessment,Class #02
ASTE-ASTE-ASSISTIVE TECHNOLOGY EVAL 9 9.000000 436.5000 48.5000
AUDE-92552-PURE TONE AUDIOMETRY -AIR ONLY 30 32.000000 404.5500 12.6422
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 109 111.000000 1011.2100 9.1100
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 64 66.000000 616.4400 9.3400
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 106 108.000000 2346.8400 21.7300
AUDE-92585-AUD EVOKED RESPONSE (DIAG) 3 3.000000 170.8200 56.9400
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 20 20.000000 489.4000 24.4700
AUDE-92588-OTOACOUSTIC EMISSIONS (COMP) 2 2.000000 54.5600 27.2800
AUDE-V5090-DISPENSING FEE PER HEARING AID 3 6.000000 690.0000 115.0000
BEHV-BEHV-BEHAVIORAL ASSESSMENT 4 4.000000 425.0000 106.2500
EVAL-EVAL-DEVELOPMENTAL EVALUATION 88 95.750000 4787.5000 50.0000
EXIT-EXIT-EXIT ASSESSMENT 378 468.000000 23400.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 111 182.500000 13687.5000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 37 58.000000 4350.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 43 51.500000 3862.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 75 117.000000 8775.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 146 224.500000 12459.7500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 1184 1848.500000 138512.5000 74.9324
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 460 765.000000 57375.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 464 633.500000 47512.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 1801 2785.000000 154567.5000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 690 862.000000 64650.0000 75.0000
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 184 184.000000 18210.7000 98.9712
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 22 22.000000 853.3400 38.7882
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 20 21.000000 1018.5000 48.5000
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 164 168.000000 8005.3900 47.6511
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 9 9.000000 436.5000 48.5000
PSTH-97001-EVAL BY LICENSED PT, INITIAL 85 86.000000 4171.0000 48.5000
SPCH-92506-SPEECH EVAL BY LICENSED SLP 187 190.000000 9166.5000 48.2447
Subtotal (Total Children Is Unduplicated) 3304 9132.250000 582447.0000 63.7791
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 19 59.000000 7764.3600 131.5993
AUD-HA_FUP-AUDIOLOGY SERVICES 2 3.000000 150.0000 50.0000
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 615 761.250000 36800.0000 48.3415
COIFP-COIFP-IFSP CONSULT, PRO, BY PHONE 49 28.500000 712.5000 25.0000
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 496 538.000000 24326.0000 45.2156
CONIP-CONIP-CONSULT, ITDS, PHONE 53 34.000000 850.0000 25.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 226 259.750000 12987.5000 50.0000
CONOP-CONOP-CONSULT, OT, PHONE 20 21.500000 537.5000 25.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 255 265.000000 13170.6800 49.7007
CONPP-CONPP-CONSULT, PT, PHONE 14 7.500000 187.5000 25.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 676 706.250000 32837.5000 46.4956
CONSP-CONSP-CONSULT, SLP, PHONE 48 21.000000 525.0000 25.0000
EIGF-EIGF_NM-EI GROUP SESSION BY NONMED PROF 3 272.000000 6800.0000 25.0000
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 96 2882.000000 72050.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 3628 30702.50000 1535095.0000 49.9990
INTR-INTR-INTERPRETER 176 819.250000 38730.5400 47.2756
OCCT-97530-OT SESSION BY LICENSED OT 853 5234.000000 349566.4400 66.7876
OCCT-97530HM-OT SESSION BY OT ASST 46 169.750000 9108.8300 53.6603
PHY-97110-PT SESSION BY LICENSED PT 959 5743.249200 374928.0000 65.2815
PHY-97110HM-PT SESSION BY PT ASST 58 304.500000 16540.4400 54.3200
SENS-HA_EIP-ONE UNIT UP TO $500 PER AID 2 4.000000 2000.0000 500.0000
SENS-HA_INS-SENSORY AID INSURANCE PER EAR 1 2.000000 105.0000 52.5000
SENS-V5050-MED HEARING AID - ANALOG/DIGITAL 1 2.000000 456.0000 228.0000
SENS-V5264-EARMOLD 9 18.000000 324.0000 18.0000
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 1586 9948.000000 670684.5126 67.4190
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 22 95.500000 5187.5600 54.3200
SPL-92508-GROUP SPL SESSION PER CHILD 43 75.250000 999.9000 13.2877
TRAN-TRAN-FAMILY TRANSPORTATION 456 470.000000 3760.0000 8.0000
TRAV-TRAV-PROV TRAVEL TO NATURAL ENV PER MINUTE 5640 1181433.000 614572.3000 0.5202
Subtotal (Total Children Is Unduplicated) 6626 1240879.749 3831757.0626 3.0879
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Total 1289545.749200 5767250.8126 4.4723
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Number of Children (Unduplicated) With at Least One Service 10624
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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 1097 717.000000 26186.7500 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 984 31453.000000 53091.5900 53091.5900
3522 39709.750000 122731.7400 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 5605 71880.250000 202028.5800 53091.5900
Center 03
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 7 4.500000 166.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 484 415.750000 18471.0000 50.0000
P 7612 105105.250000 224361.0600 224387.0600
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
13016 70571.500000 295755.2100 0.0000
Other 196 195.750000 2890.4300 0.0000
---------------------------------------------------------
Total 21315 176292.750000 541644.2000 224437.0600
Center 04
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 124 71.750000 2654.7500 0.0000
U 0 0.000000 0.0000 0.0000
B 2004 2094.250000 80461.0000 0.0000
P 5714 200582.000000 362076.5000 359623.9900
D 37 40.750000 1526.7500 0.0000
S 0 0.000000 0.0000 0.0000
H 2334 7602.000000 379741.8600 348743.9200
T 0 0.000000 0.0000 0.0000
6140 8293.000000 292167.1000 0.0000
Other 115 554.250000 15372.8700 15018.1000
---------------------------------------------------------
Total 16468 219238.000000 1134000.8300 723386.0100
Center 09
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 5 4.750000 175.7500 0.0000
U 0 0.000000 0.0000 0.0000
B 5471 5641.500000 251646.0800 0.0000
P 16855 274028.000000 770229.7200 770229.7230
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
3290 19577.250000 425469.1800 908.9600
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 25621 299251.500000 1447520.7300 771138.6830
Center 10
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 344 196.750000 7279.7500 0.0000
U 0 0.000000 0.0000 0.0000
B 2720 1718.750000 63593.7500 0.0000
P 10814 256673.000000 612676.6000 612308.7200
D 16 11.500000 425.5000 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
7276 10620.000000 544547.9100 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 21170 269220.000000 1228523.5100 612308.7200
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 0 0.000000 0.0000 0.0000
H 4 273.000000 195.0000 195.0000
T 0 0.000000 0.0000 0.0000
0 0.000000 0.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 4 273.000000 195.0000 195.0000
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 5526 58864.826371 185252.2387 185393.8300
D 39 42.000000 2321.0000 0.0000
S 3 2.500000 149.5000 0.0000
H 8 11.000000 850.0000 0.0000
T 1686 26459.654913 55932.6000 55932.6000
4795 4114.017916 193455.3339 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 12061 89496.499200 438053.1726 241326.4300
Center 57
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 183 160.250000 5929.2500 0.0000
U 0 0.000000 0.0000 0.0000
B 1195 1114.250000 44276.7500 0.0000
P 444 528.853100 28943.7500 28830.3000
D 10 12.750000 669.5000 0.0000
S 84 3457.750000 5059.2900 5059.2900
H 0 0.000000 0.0000 0.0000
T 3062 148236.732200 234707.7200 234789.7300
4437 8883.664700 452710.3100 311657.5500
Other 57 1499.500000 2988.2200 2988.2200
---------------------------------------------------------
Total 9472 163893.750000 775284.7900 583325.0900