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
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 4950 5965.750000 220658.7500 36.9876
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 1894 2035.000000 0.0000 0.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 3099 3007.500000 111259.0000 36.9938
TCM-T1017TL-TARGETED CASE MANAGEMENT 10085 33667.50000 1244701.5000 36.9704
TCON-TCON-TRANSITION CONFERENCE 314 315.000000 0.0000 0.0000
Subtotal (Total Children Is Unduplicated) 10510 44990.75000 1576619.2500 35.0432
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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 35 37.000000 530.0100 14.3246
AUDE-92553-PURE TONE AUDIOMETRY AIR & BONE 1 1.000000 18.4600 18.4600
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 88 91.000000 887.2500 9.7500
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 58 60.000000 513.9000 8.5650
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 88 91.000000 1929.9800 21.2086
AUDE-92585-AUD EVOKED RESPONSE (DIAG) 4 4.000000 233.4500 58.3625
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 26 28.000000 621.4600 22.1950
AUDE-92588-OTOACOUSTIC EMISSIONS (COMP) 1 1.000000 24.5500 24.5500
AUDE-V5090-DISPENSING FEE PER HEARING AID 1 1.000000 115.0000 115.0000
BEHV-BEHV-BEHAVIORAL ASSESSMENT 9 15.000000 1875.0000 125.0000
EVAL-EVAL-DEVELOPMENTAL EVALUATION 63 65.500000 3275.0000 50.0000
EXIT-EXIT-EXIT ASSESSMENT 363 451.250000 22562.5000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 93 149.000000 11136.5000 74.7416
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 35 47.500000 3562.5000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 31 42.000000 3150.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 79 115.500000 8662.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 119 174.000000 9657.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 995 1477.500000 110736.0000 74.9482
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 424 653.500000 49012.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 529 758.500000 56887.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 1512 2276.500000 126345.7500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 888 1180.000000 88462.5000 74.9682
MED-99202-OUTPATIENT VISIT, NEW, 20 MINS 17 17.000000 951.0800 55.9459
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 159 159.000000 15840.7800 99.6275
MED-99204-OUTPATIENT VISIT, NEW, 45 MINS 4 4.000000 591.8100 147.9525
MED-99212-OUTPATIENT VISIT, EST, 10 MINS 5 5.000000 115.6900 23.1380
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 34 34.000000 2125.0300 62.5009
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 4 4.000000 194.0000 48.5000
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 106 107.000000 5189.5000 48.5000
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 15 15.000000 727.5000 48.5000
PSTH-97001-EVAL BY LICENSED PT, INITIAL 64 64.000000 3104.0000 48.5000
SCREEN-T1023-SCREENING 3 5.000000 250.0000 50.0000
SPCH-92506-SPEECH EVAL BY LICENSED SLP 126 131.000000 6353.5000 48.5000
Subtotal (Total Children Is Unduplicated) 3018 8265.750000 535690.7000 64.8085
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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 446 593.250000 29662.5000 50.0000
COIFP-COIFP-IFSP CONSULT, PRO, BY PHONE 46 30.750000 768.7500 25.0000
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 205 187.500000 9375.0000 50.0000
CONIP-CONIP-CONSULT, ITDS, PHONE 5 3.000000 75.0000 25.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 150 141.750000 7087.5000 50.0000
CONOP-CONOP-CONSULT, OT, PHONE 4 2.250000 56.2500 25.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 228 270.250000 13512.5000 50.0000
CONPP-CONPP-CONSULT, PT, PHONE 1 0.500000 12.5000 25.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 355 359.250000 17962.5000 50.0000
CONSP-CONSP-CONSULT, SLP, PHONE 28 18.250000 456.2500 25.0000
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 127 4668.000000 116700.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 3479 30436.75000 1521517.5000 49.9895
INTR-INTR-INTERPRETER 222 530.250000 26362.5000 49.7171
OCCT-97530-OT SESSION BY LICENSED OT 705 4800.250000 323113.4900 67.3118
OCCT-97530HM-OT SESSION BY OT ASST 54 303.000000 16214.5200 53.5133
PHY-97110-PT SESSION BY LICENSED PT 810 4670.000000 312481.4800 66.9125
PHY-97110HM-PT SESSION BY PT ASST 55 300.250000 16224.5800 54.0369
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 1297 8455.500000 570995.4100 67.5295
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 47 176.000000 9560.3200 54.3200
SPL-92508-GROUP SPL SESSION PER CHILD 28 25.000000 330.0000 13.2000
TRAN-TRAN-FAMILY TRANSPORTATION 462 479.000000 3832.0000 8.0000
TRAV-FLAT-PROV TRAVEL TO NATL ENV $10 PER CHILD 2847 31006.00000 310050.0000 9.9997
TRAV-TRAV-PROV TRAVEL TO NATURAL ENV PER MINUTE 1626 314407.0000 161057.9000 0.5123
Subtotal (Total Children Is Unduplicated) 5553 401885.7500 3475857.0700 8.6489
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Total 455142.250000 5588167.0200 12.2778
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Number of Children (Unduplicated) With at Least One Service 11012
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Center 02
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 48 28.250000 1082.2500 0.0000
U 0 0.000000 0.0000 0.0000
B 794 526.500000 20209.2500 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
2063 1465.000000 40688.7500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 2909 2025.750000 62314.9900 334.7400
Center 03
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 40 31.000000 1324.7500 0.0000
U 0 0.000000 0.0000 0.0000
B 1803 1245.000000 52756.3600 9.2500
P 1568 991.750000 41511.2500 41511.2550
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
8394 26500.750000 191798.4500 0.0000
Other 135 135.000000 2083.8900 0.0000
---------------------------------------------------------
Total 11940 28903.500000 289474.7000 41520.5050
Center 04
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 33 27.500000 1853.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 1855 2331.250000 89373.7500 0.0000
P 6194 15654.500000 370904.9200 345060.3700
D 63 73.250000 2710.2500 0.0000
S 2 1.250000 46.2500 0.0000
H 2464 8200.250000 414729.2000 297901.2000
T 0 0.000000 0.0000 0.0000
5883 9325.500000 318032.3700 0.0000
Other 104 252.750000 15517.9900 9822.1400
---------------------------------------------------------
Total 16598 35866.250000 1213168.2300 652783.7100
Center 09
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 6926 6704.250000 292948.6500 55.5000
P 19574 285264.500000 844301.8700 844355.1200
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
2703 10169.250000 395354.0400 80.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 29203 302138.000000 1532604.5600 844490.6200
Center 10
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 79 48.250000 1785.2500 0.0000
U 0 0.000000 0.0000 0.0000
B 8243 5496.750000 215247.5000 0.0000
P 7564 21992.750000 600879.3300 600719.3300
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
8307 11669.000000 581334.6100 0.0000
Other 3 4.000000 281.0000 0.0000
---------------------------------------------------------
Total 24196 39210.750000 1399527.6900 600719.3300
Center 55
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 4 3.000000 111.0000 0.0000
P 1464 1415.250000 56110.7500 56053.6600
D 45 50.750000 3058.7500 0.0000
S 0 0.000000 0.0000 0.0000
H 18 27.000000 2025.0000 0.0000
T 0 0.000000 0.0000 0.0000
2001 1700.250000 68635.7500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 3532 3196.250000 129941.2500 56053.6600
Center 57
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 33 22.500000 832.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 1710 1355.250000 55035.5000 0.0000
P 1309 1298.750000 54936.3200 54890.0700
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 3271 28873.500000 262018.3100 262018.3100
6519 11635.000000 579175.1100 343510.3600
Other 41 119.500000 2756.2200 2756.2200
---------------------------------------------------------
Total 12994 43801.750000 961135.6000 668239.1000