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:TPIN
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 11 10.750000 388.5000 36.1395
Subtotal (Total Children Is Unduplicated) 11 10.750000 388.5000 36.1395
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Screening, Eval, and Assessment,Class #02
AUDE-92552-PURE TONE AUDIOMETRY -AIR ONLY 1 1.000000 9.2000 9.2000
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 24 25.000000 227.7500 9.1100
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 10 11.000000 102.7400 9.3400
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 24 25.000000 543.2500 21.7300
BEHV-BEHV-BEHAVIORAL ASSESSMENT 1 1.000000 125.0000 125.0000
EVAL-EVAL-DEVELOPMENTAL EVALUATION 5 14.000000 700.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 30 53.500000 4012.5000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 8 13.500000 1012.5000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 9 14.500000 1087.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 19 33.500000 2512.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 22 38.500000 2136.7500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 265 462.101700 34607.6300 74.8918
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 103 178.268000 13370.1000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 110 188.500000 14137.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 294 503.000000 27916.5000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 167 229.823333 17236.7500 75.0000
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 39 39.000000 10920.0000 280.0000
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 1 1.000000 180.0000 180.0000
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 14 14.000000 631.3200 45.0943
PSTH-97001-EVAL BY LICENSED PT, INITIAL 10 10.000000 485.0000 48.5000
SPCH-92506-SPEECH EVAL BY LICENSED SLP 26 27.000000 1275.9500 47.2574
Subtotal (Total Children Is Unduplicated) 633 1883.193033 133230.4400 70.7471
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 2 7.000000 690.1000 98.5857
AUD-HA_FUP-AUDIOLOGY SERVICES 1 0.316000 15.8000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 33 186.000000 9300.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 97 380.049687 25453.0200 66.9729
OCCT-97530HM-OT SESSION BY OT ASST 7 13.500000 726.9300 53.8467
PHY-97110-PT SESSION BY LICENSED PT 192 806.304500 53509.3300 66.3637
PHY-97110HM-PT SESSION BY PT ASST 9 29.159200 1583.9300 54.3201
SENS-V5264-EARMOLD 1 2.000000 36.0000 18.0000
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 244 1094.722162 73815.9113 67.4289
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 3 8.000000 434.5600 54.3200
SPL-92508-GROUP SPL SESSION PER CHILD 12 25.500000 343.2000 13.4588
TRAV-TRAV-PROV TRAVEL TO NATURAL ENV PER MINUTE 3 177.000000 110.7000 0.6254
Subtotal (Total Children Is Unduplicated) 484 2729.551549 166019.4813 60.8230
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Total 4623.494582 299638.4213 64.8078
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Number of Children (Unduplicated) With at Least One Service 1062
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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 0 0.000000 0.0000 0.0000
18 18.250000 951.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 18 18.250000 951.0000 0.0000
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
99 139.750000 8614.6500 0.0000
Other 57 57.000000 811.8300 0.0000
---------------------------------------------------------
Total 156 196.750000 9426.4800 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 47 167.000000 7465.6200 7300.8000
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 7 9.000000 448.5000 83.9400
T 0 0.000000 0.0000 0.0000
117 107.500000 13774.2500 0.0000
Other 59 119.500000 7661.5400 7661.5400
---------------------------------------------------------
Total 230 403.000000 29349.9100 15046.2800
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 63 148.000000 9147.3200 9147.3230
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
910 1417.000000 97177.6400 799.8000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 973 1565.000000 106324.9600 9947.1230
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
807 1469.250000 95658.2000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 807 1469.250000 95658.2000 0.0000
Center 55
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 0 0.000000 0.0000 0.0000
P 3 3.323333 249.2500 390.8400
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 8 11.000000 850.0000 0.0000
T 0 0.000000 0.0000 0.0000
526 541.153449 29197.9613 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 537 555.476782 30297.2113 390.8400
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 1 0.103100 5.0000 5.0000
D 0 0.000000 0.0000 0.0000
S 2 2.000000 116.3800 116.3800
H 0 0.000000 0.0000 0.0000
T 5 21.500000 1119.7000 1119.7000
195 392.164700 26389.5800 26221.3800
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 203 415.767800 27630.6600 27462.4600