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
Payclass Filters:GR
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 8372.250000 309634.5000 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 3263 10438.25000 386104.2500 36.9894
TCON-TCON-TRANSITION CONFERENCE 398 398.000000 0.0000 0.0000
Subtotal (Total Children Is Unduplicated) 8184 24665.75000 798729.2500 32.3821
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Screening, Eval, and Assessment,Class #02
ASTE-ASTE-ASSISTIVE TECHNOLOGY EVAL 3 3.000000 145.5000 48.5000
AUDE-92552-PURE TONE AUDIOMETRY -AIR ONLY 47 50.000000 641.1600 12.8232
AUDE-92553-PURE TONE AUDIOMETRY AIR & BONE 3 3.000000 44.0800 14.6933
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 54 57.000000 519.2700 9.1100
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 50 52.000000 480.2600 9.2358
AUDE-92568-ACOUSTIC REFLEX TESTING (MEMR) 1 1.000000 7.9300 7.9300
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 53 56.000000 1189.3700 21.2388
AUDE-92585-AUD EVOKED RESPONSE (DIAG) 1 1.000000 56.9400 56.9400
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 35 35.000000 845.1500 24.1471
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 93 104.000000 5200.0000 50.0000
EXIT-EXIT-EXIT ASSESSMENT 391 467.750000 23387.5000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 19 31.000000 2325.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 10 15.500000 1162.5000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 10 13.000000 975.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 24 21.500000 1612.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 33 57.000000 3163.5000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 348 478.014566 35520.3400 74.3081
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 84 148.431700 11132.3775 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 100 145.500000 10912.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 545 835.500000 46370.2500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 237 259.887333 19491.5500 75.0000
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 54 54.000000 2197.1300 40.6876
MED-99204-OUTPATIENT VISIT, NEW, 45 MINS 1 1.000000 57.2700 57.2700
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 2 2.000000 44.2800 22.1400
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 32 32.000000 1552.0000 48.5000
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 61 60.072200 2850.4600 47.4506
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 8 8.000000 388.0000 48.5000
PSTH-97001-EVAL BY LICENSED PT, INITIAL 33 32.278557 1485.0500 46.0073
SPCH-92506-SPEECH EVAL BY LICENSED SLP 89 89.272300 4299.7100 48.1640
Subtotal (Total Children Is Unduplicated) 1577 3122.706656 178986.1375 57.3176
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 16 36.449549 12199.3600 334.6917
AUD-HA_FUP-AUDIOLOGY SERVICES 3 2.206200 110.3100 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 257 279.000000 13950.0000 50.0000
CONOP-CONOP-CONSULT, OT, PHONE 12 17.250000 431.2500 25.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 317 338.750000 16937.5000 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-T1027TTSC-EI GROUP SESSION BY EI PROF 11 66.000000 1650.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 1314 10900.00000 545000.0000 50.0000
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 513 3038.168656 202246.4600 66.5685
OCCT-97530HM-OT SESSION BY OT ASST 43 175.477100 9374.1500 53.4209
PHY-97110-PT SESSION BY LICENSED PT 509 2773.864554 177014.7900 63.8152
PHY-97110HM-PT SESSION BY PT ASST 9 41.000000 2227.1200 54.3200
SENS-V5264-EARMOLD 1 2.000000 36.0000 18.0000
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 1085 6842.301156 455857.4900 66.6234
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 23 103.500000 5622.1200 54.3200
TRAN-TRAN-FAMILY TRANSPORTATION 484 495.000000 3960.0000 8.0000
TRAV-FLAT-PROV TRAVEL TO NATL ENV $10 PER CHILD 2935 31814.00000 318110.0000 9.9991
TRAV-TRAV-PROV TRAVEL TO NATURAL ENV PER MINUTE 3039 630692.0000 341761.5000 0.5419
Subtotal (Total Children Is Unduplicated) 6628 690886.7172 2258544.7400 3.2691
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Total 718675.173871 3236260.1275 4.5031
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Number of Children (Unduplicated) With at Least One Service 9838
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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 85 2075.000000 3524.7400 3524.7400
5215 85140.250000 190994.5400 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 5300 87215.250000 194519.2800 3524.7400
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 2895 50190.250000 84826.5400 84826.5400
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
16061 116905.500000 395388.5100 0.0000
Other 13 13.000000 197.3500 0.0000
---------------------------------------------------------
Total 18969 167108.750000 480412.4000 84826.5400
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 4535 15644.750000 309515.7000 245125.9500
D 36 40.500000 1498.5000 1156.2500
S 0 0.000000 0.0000 0.0000
H 9 26.000000 962.0200 569.7200
T 0 0.000000 0.0000 0.0000
5273 4536.250000 143024.9300 0.0000
Other 7 17.000000 845.1800 513.2300
---------------------------------------------------------
Total 9860 20264.500000 455846.3300 247365.1500
Center 09
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 2 3.750000 138.7500 0.0000
P 18393 291541.250000 809936.3000 809936.3000
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 0 0.000000 0.0000 0.0000
315 3204.500000 20263.2000 294.9400
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 18710 294749.500000 830338.2500 810231.2400
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 7115 20582.000000 516660.2600 516660.2600
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
4146 2966.250000 114068.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 11288 23566.000000 631498.0100 516660.2600
Center 55
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 0 0.000000 0.0000 0.0000
P 3716 60935.095573 111957.2300 111957.2300
D 71 82.500000 4337.5000 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 1671 26722.933265 54815.5175 54815.5200
2186 1805.946133 47325.3500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 7644 89546.474971 218435.5975 166772.7500
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 -3.000000 -150.0000 -150.0000
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 3412 32627.198900 276818.0900 276818.0900
4894 3461.500000 143096.0900 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 8399 36224.698900 425210.2600 281596.1700