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:Program Patients
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 5922 17811.50000 658498.2500 36.9704
Subtotal (Total Children Is Unduplicated) 5922 17811.50000 658498.2500 36.9704
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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) 52 52.000000 473.7200 9.1100
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 22 22.000000 205.4800 9.3400
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 50 50.000000 1086.5000 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 65 106.500000 7987.5000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 24 37.500000 2812.5000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 27 29.000000 2175.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 34 62.000000 4650.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 92 135.500000 7520.2500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 629 971.500000 72862.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 268 430.000000 32250.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 280 354.500000 26587.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 1051 1572.500000 87273.7500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 310 424.500000 31837.5000 75.0000
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 139 139.000000 7037.5700 50.6300
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 20 20.000000 651.2000 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 33 34.000000 1649.0000 48.5000
SPCH-92506-SPEECH EVAL BY LICENSED SLP 48 48.000000 2328.0000 48.5000
Subtotal (Total Children Is Unduplicated) 1610 4568.500000 293188.5300 64.1761
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 2409 20092.25000 1004612.5000 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) 3073 26703.75000 1447272.5600 54.1974
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Total 49083.750000 2398959.3400 48.8748
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Number of Children (Unduplicated) With at Least One Service 6631
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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 0 0.000000 0.0000 0.0000
128 230.750000 15864.5000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 1227 948.250000 42069.7500 0.0000
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 1776 1125.750000 46223.7500 46249.7500
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
4 5.250000 320.2500 0.0000
Other 123 122.750000 1856.2000 0.0000
---------------------------------------------------------
Total 2394 1674.000000 67037.7000 46299.7500
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 1537 1907.250000 74005.9000 73963.7600
D 1 1.250000 46.2500 0.0000
S 0 0.000000 0.0000 0.0000
H 2323 7490.500000 379091.5400 348468.1600
T 0 0.000000 0.0000 0.0000
622 774.000000 45886.9100 0.0000
Other 3 2.250000 83.2500 0.0000
---------------------------------------------------------
Total 6614 12341.250000 582229.6000 422431.9200
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 317 347.000000 17040.0000 17040.0000
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
1874 5465.500000 301708.5200 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 7667 11458.750000 570570.3500 17040.0000
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 4250 3508.000000 166487.6300 166119.7500
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
2169 6068.000000 329886.2100 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 9483 11491.500000 567247.3400 166119.7500
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 2222 2117.750000 82483.7500 82483.7500
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
2124 1922.000000 122234.0300 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 4352 4044.250000 204941.2800 82483.7500
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 443 528.750000 28938.7500 28825.3000
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
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Total 3425 7125.750000 364863.3200 313984.3700