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: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 2 2.250000 83.2500 37.0000
Subtotal (Total Children Is Unduplicated) 2 2.250000 83.2500 37.0000
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Screening, Eval, and Assessment,Class #02
ASTE-ASTE-ASSISTIVE TECHNOLOGY EVAL 1 1.000000 48.5000 48.5000
AUDE-92552-PURE TONE AUDIOMETRY -AIR ONLY 2 2.000000 24.3900 12.1950
AUDE-92553-PURE TONE AUDIOMETRY AIR & BONE 1 1.000000 16.7800 16.7800
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 35 36.000000 327.9600 9.1100
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 15 15.000000 136.1800 9.0787
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 36 37.000000 797.8900 21.5646
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 1 1.000000 11.3000 11.3000
EVAL-EVAL-DEVELOPMENTAL EVALUATION 2 3.000000 150.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 37 69.000000 5175.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 14 23.500000 1762.5000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 11 18.500000 1387.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 22 42.500000 3187.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 27 49.000000 2719.5000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 254 435.985434 32698.9100 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 98 166.568290 12492.6200 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 159 266.500000 19987.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 256 468.000000 25974.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 200 280.112667 21008.4500 75.0000
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 52 52.000000 14560.0000 280.0000
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 2 2.000000 360.0000 180.0000
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 1 1.000000 48.5000 48.5000
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 23 22.927800 1112.0000 48.5001
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 1 1.000000 48.5000 48.5000
PSTH-97001-EVAL BY LICENSED PT, INITIAL 21 19.721443 956.4900 48.5000
SPCH-92506-SPEECH EVAL BY LICENSED SLP 31 30.727700 1466.7900 47.7351
Subtotal (Total Children Is Unduplicated) 685 2045.043334 146458.7600 71.6165
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 2 6.550451 946.9700 144.5656
AUD-HA_FUP-AUDIOLOGY SERVICES 2 1.793800 89.6900 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 30 191.000000 9550.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 122 469.256359 31497.2400 67.1216
OCCT-97530HM-OT SESSION BY OT ASST 17 28.272900 1466.2100 51.8592
PHY-97110-PT SESSION BY LICENSED PT 232 896.635446 60035.2200 66.9561
PHY-97110HM-PT SESSION BY PT ASST 8 26.500000 1439.4800 54.3200
SENS-V5264-EARMOLD 1 1.000000 18.0000 18.0000
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 297 1302.948844 87757.1800 67.3527
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 1 2.000000 108.6400 54.3200
Subtotal (Total Children Is Unduplicated) 570 2925.957800 192908.6300 65.9301
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Total 4973.251134 339450.6400 68.2553
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Number of Children (Unduplicated) With at Least One Service 1143
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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
5 8.250000 590.2500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 5 8.250000 590.2500 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
124 174.500000 12235.8500 0.0000
Other 82 82.000000 1186.5300 0.0000
---------------------------------------------------------
Total 206 256.500000 13422.3800 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 30 67.000000 4538.6800 4382.6800
D 2 2.000000 560.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 6 16.000000 800.0000 200.0000
T 0 0.000000 0.0000 0.0000
121 109.500000 17550.2500 0.0000
Other 86 214.500000 14073.7400 8254.8000
---------------------------------------------------------
Total 245 409.000000 37522.6700 12837.4800
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 42 108.500000 6791.5600 7684.2300
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
949 1464.500000 100288.5000 2316.2200
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 991 1573.000000 107080.0600 10000.4500
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
871 1618.750000 107178.7000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 871 1618.750000 107178.7000 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 10 6.612667 413.2300 445.7300
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 5 7.500000 562.5000 0.0000
T 11 8.500000 560.5400 560.5400
667 520.337367 35031.7700 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 693 542.950034 36568.0400 1006.2700
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 9 15.051100 966.7100 966.7100
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 16 64.500000 3609.4200 3609.4200
218 485.250000 32512.4100 32512.4100
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 243 564.801100 37088.5400 37088.5400