CMS/EIP Fiscal Report Statewide
Services beginning 04/01/2013 ending 06/30/2013 Date of Report:08/19/2013 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 5502 8373.750000 309690.0000 36.9834
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 2374 2672.000000 0.0000 0.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 2883 2785.250000 102990.5000 36.9771
TCM-T1017TL-TARGETED CASE MANAGEMENT 9355 30198.00000 1116851.0000 36.9843
TCON-TCON-TRANSITION CONFERENCE 398 398.000000 0.0000 0.0000
Subtotal (Total Children Is Unduplicated) 10408 44427.00000 1529531.5000 34.4280
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Screening, Eval, and Assessment,Class #02
ASTE-ASTE-ASSISTIVE TECHNOLOGY EVAL 4 4.000000 194.0000 48.5000
AUDE-92552-PURE TONE AUDIOMETRY -AIR ONLY 47 52.000000 665.5500 12.7990
AUDE-92553-PURE TONE AUDIOMETRY AIR & BONE 5 5.000000 77.6400 15.5280
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 124 131.000000 1193.4100 9.1100
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 82 88.000000 812.5800 9.2339
AUDE-92568-ACOUSTIC REFLEX TESTING (MEMR) 1 1.000000 7.9300 7.9300
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 122 130.000000 2791.2700 21.4713
AUDE-92585-AUD EVOKED RESPONSE (DIAG) 1 1.000000 56.9400 56.9400
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 35 36.000000 856.4500 23.7903
AUDE-92588-OTOACOUSTIC EMISSIONS (COMP) 2 2.000000 54.5600 27.2800
BEHV-BEHV-BEHAVIORAL ASSESSMENT 7 7.000000 875.0000 125.0000
EVAL-EVAL-DEVELOPMENTAL EVALUATION 93 107.000000 5350.0000 50.0000
EXIT-EXIT-EXIT ASSESSMENT 391 467.750000 23387.5000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 120 205.000000 15375.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 52 78.000000 5850.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 45 70.500000 5287.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 78 120.000000 8970.7500 74.7563
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 159 260.000000 14430.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 1304 1977.000000 147944.2500 74.8327
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 461 784.499990 58837.4975 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 594 880.000000 66000.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 1998 3148.500000 174741.7500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 839 1073.000000 80445.7500 74.9727
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 218 218.000000 22417.5600 102.8328
MED-99204-OUTPATIENT VISIT, NEW, 45 MINS 1 1.000000 57.2700 57.2700
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 27 27.000000 1153.1600 42.7096
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 45 45.000000 2182.5000 48.5000
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 104 105.000000 5029.4600 47.8996
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 21 21.000000 1018.5000 48.5000
PSTH-97001-EVAL BY LICENSED PT, INITIAL 75 76.000000 3605.5400 47.4413
SPCH-92506-SPEECH EVAL BY LICENSED SLP 155 159.000000 7658.0000 48.1635
Subtotal (Total Children Is Unduplicated) 3540 10280.24999 657327.3175 63.9408
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 18 45.000000 13426.1300 298.3584
AUD-HA_FUP-AUDIOLOGY SERVICES 4 4.000000 200.0000 50.0000
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 655 853.250000 42662.5000 50.0000
COIFP-COIFP-IFSP CONSULT, PRO, BY PHONE 55 32.500000 812.5000 25.0000
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 515 552.750000 27647.5000 50.0181
CONIP-CONIP-CONSULT, ITDS, PHONE 26 25.000000 625.0000 25.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 259 281.000000 14050.0000 50.0000
CONOP-CONOP-CONSULT, OT, PHONE 12 17.250000 431.2500 25.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 318 339.750000 16987.5000 50.0000
CONPP-CONPP-CONSULT, PT, PHONE 15 5.750000 143.7500 25.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 654 701.250000 33825.0000 48.2353
CONSP-CONSP-CONSULT, SLP, PHONE 24 13.000000 325.0000 25.0000
EIGF-EIGF_NM-EI GROUP SESSION BY NONMED PROF 1 188.000000 4700.0000 25.0000
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 100 3355.000000 83875.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 3812 33371.25000 1668366.5000 49.9941
HERN-T1027SC-EI HEARING SERVICES AFTER SHINE 1 6.000000 300.0000 50.0000
INTR-INTR-INTERPRETER 212 1080.250000 45715.4400 42.3193
OCCT-97530-OT SESSION BY LICENSED OT 920 5506.425015 369435.8200 67.0918
OCCT-97530HM-OT SESSION BY OT ASST 74 319.500000 17127.9000 53.6085
PHY-97110-PT SESSION BY LICENSED PT 1105 6070.750000 399978.9800 65.8863
PHY-97110HM-PT SESSION BY PT ASST 48 237.250000 12887.4200 54.3200
SENS-V5264-EARMOLD 2 3.000000 54.0000 18.0000
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 1764 11122.50000 745676.4600 67.0422
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 29 125.500000 6817.1600 54.3200
SPL-92508-GROUP SPL SESSION PER CHILD 2 4.000000 52.8000 13.2000
TRAN-TRAN-FAMILY TRANSPORTATION 484 495.000000 3960.0000 8.0000
TRAV-FLAT-PROV TRAVEL TO NATL ENV $10 PER CHILD 2936 31849.00000 318460.0000 9.9991
TRAV-TRAV-PROV TRAVEL TO NATURAL ENV PER MINUTE 3039 630692.0000 341761.5000 0.5419
Subtotal (Total Children Is Unduplicated) 7071 727295.9250 4170305.1100 5.7340
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Total 782003.175005 6357163.9275 8.1293
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Number of Children (Unduplicated) With at Least One Service 11121
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Center 02
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 1 0.500000 18.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 1194 735.250000 27139.5000 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 85 2075.000000 3524.7400 3524.7400
5390 85460.750000 212537.7900 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 6670 88271.500000 243220.5300 3524.7400
Center 03
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 4 1.250000 46.2500 0.0000
U 0 0.000000 0.0000 0.0000
B 662 514.750000 23657.5000 0.0000
P 4644 51602.750000 148650.2900 148462.7900
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
16192 117083.500000 407959.6600 0.0000
Other 195 195.000000 2857.9900 0.0000
---------------------------------------------------------
Total 21697 169397.250000 583171.6900 148462.7900
Center 04
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 4 4.250000 157.2500 0.0000
U 0 0.000000 0.0000 0.0000
B 1263 1487.250000 57071.0000 0.0000
P 7430 18974.750000 439512.6900 375968.1900
D 38 42.500000 2058.5000 1156.2500
S 0 0.000000 0.0000 0.0000
H 2481 8398.000000 424968.7000 297430.8700
T 0 0.000000 0.0000 0.0000
6353 8414.250000 292543.8400 0.0000
Other 99 235.750000 15076.1700 8768.0300
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Total 17668 37556.750000 1231388.1500 683323.3400
Center 09
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 82 77.750000 2876.7500 0.0000
U 0 0.000000 0.0000 0.0000
B 1332 1278.000000 63258.4200 46.2500
P 23430 296560.500000 1029155.5100 1029917.3700
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 1 0.500000 18.5000 18.5000
T 0 0.000000 0.0000 0.0000
3426 10490.500000 439985.5100 2611.1600
Other 7 7.750000 362.7500 307.2500
---------------------------------------------------------
Total 28278 308415.000000 1535657.4400 1032900.5300
Center 10
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 478 333.000000 12548.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 6148 3936.750000 150540.0000 0.0000
P 7818 21733.000000 593270.2600 592400.2600
D 27 17.750000 769.7500 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
7478 11627.250000 608289.4400 0.0000
Other 2 2.500000 148.5000 0.0000
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Total 21951 37650.250000 1365565.9500 592400.2600
Center 55
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 14 11.250000 473.2500 0.0000
P 5872 63026.958240 194593.4600 194655.2100
D 71 82.500000 4337.5000 0.0000
S 0 0.000000 0.0000 0.0000
H 5 7.500000 562.5000 0.0000
T 1682 26731.433265 55376.0575 55376.0600
5189 4465.033500 219642.6400 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 12833 94324.675005 474985.4075 250031.2700
Center 57
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 19 15.000000 555.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 1421 1167.250000 43994.8900 0.0000
P 1302 1424.301100 65565.4600 65564.5600
D 15 14.000000 518.0000 0.0000
S 77 125.000000 4928.0800 4928.0800
H 0 0.000000 0.0000 0.0000
T 3429 32692.698900 280437.5100 280437.5100
7048 10899.500000 525894.2800 331199.8500
Other 23 50.000000 1281.5400 1281.5400
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Total 13334 46387.750000 923174.7600 683411.5400