CMS/EIP Fiscal Report Statewide
Services beginning 10/01/2013 ending 12/31/2013 Date of Report:02/18/2014 Page: 1
List order: No List
Payclass Filters:GR
Eligibility Filter:Part C (excluding not eligible)
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
CASE-CASE-NON-TCM CASE MANAGEMENT 4668 5675.500000 209919.5000 36.9870
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 1759 1900.000000 0.0000 0.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 2857 2819.000000 104284.5000 36.9934
TCM-T1017TL-TARGETED CASE MANAGEMENT 3507 11244.25000 415750.5000 36.9745
TCON-TCON-TRANSITION CONFERENCE 314 315.000000 0.0000 0.0000
Subtotal (Total Children Is Unduplicated) 7464 21953.75000 729954.5000 33.2497
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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 31 33.000000 472.5700 14.3203
AUDE-92553-PURE TONE AUDIOMETRY AIR & BONE 1 1.000000 18.4600 18.4600
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 38 40.000000 398.9800 9.9745
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 35 37.000000 311.1700 8.4100
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 38 40.000000 840.7300 21.0183
AUDE-92585-AUD EVOKED RESPONSE (DIAG) 2 2.000000 119.5700 59.7850
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 21 23.000000 508.9100 22.1265
AUDE-92588-OTOACOUSTIC EMISSIONS (COMP) 1 1.000000 24.5500 24.5500
BEHV-BEHV-BEHAVIORAL ASSESSMENT 9 15.000000 1875.0000 125.0000
EVAL-EVAL-DEVELOPMENTAL EVALUATION 61 60.500000 3025.0000 50.0000
EXIT-EXIT-EXIT ASSESSMENT 363 451.250000 22562.5000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 15 21.000000 1575.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 8 15.000000 1125.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 8 10.500000 787.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 8 11.000000 825.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 41 62.500000 3468.7500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 152 207.500000 15523.5000 74.8120
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 49 88.500000 6637.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 94 137.500000 10312.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 373 596.000000 33078.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 108 145.000000 10875.0000 75.0000
MED-99202-OUTPATIENT VISIT, NEW, 20 MINS 2 2.000000 54.4400 27.2200
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 84 84.000000 3402.0000 40.5000
MED-99204-OUTPATIENT VISIT, NEW, 45 MINS 3 3.000000 171.8100 57.2700
MED-99212-OUTPATIENT VISIT, EST, 10 MINS 2 2.000000 36.3400 18.1700
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 15 15.000000 332.1000 22.1400
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 2 2.000000 97.0000 48.5000
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 75 75.000000 3637.5000 48.5000
PSTH-97001-EVAL BY LICENSED PT, INITIAL 23 23.000000 1115.5000 48.5000
SPCH-92506-SPEECH EVAL BY LICENSED SLP 82 86.000000 4171.0000 48.5000
Subtotal (Total Children Is Unduplicated) 1202 2291.250000 127431.3800 55.6165
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 7 17.000000 7362.6200 433.0953
AUD-HA_FUP-AUDIOLOGY SERVICES 1 1.000000 50.0000 50.0000
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 444 589.750000 29487.5000 50.0000
COIFP-COIFP-IFSP CONSULT, PRO, BY PHONE 46 30.750000 768.7500 25.0000
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 160 142.500000 7125.0000 50.0000
CONIP-CONIP-CONSULT, ITDS, PHONE 5 3.000000 75.0000 25.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 134 121.500000 6075.0000 50.0000
CONOP-CONOP-CONSULT, OT, PHONE 3 1.250000 31.2500 25.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 210 251.750000 12587.5000 50.0000
CONPP-CONPP-CONSULT, PT, PHONE 1 0.500000 12.5000 25.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 314 311.000000 15550.0000 50.0000
CONSP-CONSP-CONSULT, SLP, PHONE 28 17.750000 443.7500 25.0000
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 4 6.000000 150.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 1055 9056.250000 452812.5000 50.0000
INTR-INTR-INTERPRETER 174 437.500000 21725.0000 49.6571
OCCT-97530-OT SESSION BY LICENSED OT 373 2310.750000 155143.8800 67.1401
OCCT-97530HM-OT SESSION BY OT ASST 39 204.000000 10967.2200 53.7609
PHY-97110-PT SESSION BY LICENSED PT 360 1981.750000 130648.4700 65.9258
PHY-97110HM-PT SESSION BY PT ASST 19 75.500000 4016.1600 53.1942
SENS-HA_EIP-ONE UNIT UP TO $500 PER AID 1 2.000000 1000.0000 500.0000
SENS-V5264-EARMOLD 1 2.000000 36.0000 18.0000
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 780 5111.250000 344588.8600 67.4177
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 39 140.000000 7604.8000 54.3200
SPL-92508-GROUP SPL SESSION PER CHILD 1 1.000000 13.2000 13.2000
TRAN-TRAN-FAMILY TRANSPORTATION 365 377.000000 3016.0000 8.0000
TRAV-FLAT-PROV TRAVEL TO NATL ENV $10 PER CHILD 2844 30916.00000 309150.0000 9.9997
TRAV-TRAV-PROV TRAVEL TO NATURAL ENV PER MINUTE 1493 233919.0000 120776.3000 0.5163
Subtotal (Total Children Is Unduplicated) 4960 286027.7500 1641217.2600 5.7380
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Total 310272.750000 2498603.1400 8.0529
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Number of Children (Unduplicated) With at Least One Service 8868
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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 4 6.000000 334.7400 334.7400
2051 1458.000000 40429.7500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 2055 1464.000000 40764.4900 334.7400
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 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
8242 26319.000000 179058.7600 0.0000
Other 18 18.000000 300.9900 0.0000
---------------------------------------------------------
Total 8260 26337.000000 179359.7500 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 4170 13134.250000 270118.7600 243012.0500
D 61 71.000000 2627.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 19 52.000000 697.8800 681.4800
T 0 0.000000 0.0000 0.0000
3919 3551.250000 111726.4400 0.0000
Other 15 47.500000 2283.0800 2034.8300
---------------------------------------------------------
Total 8184 16856.000000 387453.1600 245728.3600
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 17350 206754.750000 768884.2500 768884.2500
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
127 927.500000 9856.4000 80.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 17477 207682.250000 778740.6500 768964.2500
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 7135 21334.250000 556584.4200 556584.4200
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
4935 3446.750000 132155.5000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 12070 24781.000000 688739.9200 556584.4200
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 0 0.000000 0.0000 0.0000
D 45 50.750000 3058.7500 0.0000
S 0 0.000000 0.0000 0.0000
H 1 1.500000 112.5000 0.0000
T 0 0.000000 0.0000 0.0000
1509 1161.500000 39955.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 1555 1213.750000 43126.2500 0.0000
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 0 0.000000 0.0000 0.0000
D 36 30.250000 1317.5000 0.0000
S 75 467.000000 5064.1400 5064.1400
H 0 0.000000 0.0000 0.0000
T 3259 28648.000000 260019.7300 260019.7300
3881 2793.500000 114017.5500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 7251 31938.750000 380418.9200 265083.8700