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: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 4927 5954.000000 220224.0000 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 3801 12375.25000 457597.5000 36.9768
TCON-TCON-TRANSITION CONFERENCE 314 315.000000 0.0000 0.0000
Subtotal (Total Children Is Unduplicated) 8020 23686.75000 789080.5000 33.3132
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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) 42 44.000000 439.0600 9.9786
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 39 41.000000 344.8100 8.4100
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 42 44.000000 924.7300 21.0166
AUDE-92585-AUD EVOKED RESPONSE (DIAG) 2 2.000000 119.5700 59.7850
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 24 26.000000 574.9700 22.1142
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 62 61.500000 3075.0000 50.0000
EXIT-EXIT-EXIT ASSESSMENT 363 451.250000 22562.5000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 18 24.500000 1837.5000 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 10 11.500000 862.5000 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 42 64.500000 3579.7500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 198 268.000000 20061.0000 74.8545
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 56 99.000000 7425.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 110 156.000000 11700.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 433 672.500000 37323.7500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 133 173.000000 12975.0000 75.0000
MED-99202-OUTPATIENT VISIT, NEW, 20 MINS 14 14.000000 381.0800 27.2200
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 114 114.000000 4617.0000 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
SCREEN-T1023-SCREENING 1 3.000000 150.0000 50.0000
SPCH-92506-SPEECH EVAL BY LICENSED SLP 82 86.000000 4171.0000 48.5000
Subtotal (Total Children Is Unduplicated) 1344 2556.750000 142960.9900 55.9151
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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 222 530.250000 26362.5000 49.7171
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 781 5111.750000 344622.8000 67.4178
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 462 479.000000 3832.0000 8.0000
TRAV-FLAT-PROV TRAVEL TO NATL ENV $10 PER CHILD 2845 30920.00000 309190.0000 9.9997
TRAV-TRAV-PROV TRAVEL TO NATURAL ENV PER MINUTE 1505 234887.0000 121297.9000 0.5164
Subtotal (Total Children Is Unduplicated) 5117 287195.0000 1647266.3000 5.7357
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Total 313438.500000 2579307.7900 8.2291
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Number of Children (Unduplicated) With at Least One Service 9451
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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
2062 1463.500000 40633.2500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 2066 1469.500000 40967.9900 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
8273 26332.500000 179521.2600 0.0000
Other 18 18.000000 300.9900 0.0000
---------------------------------------------------------
Total 8291 26350.500000 179822.2500 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 63 73.250000 2710.2500 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
4606 4340.000000 134418.0800 0.0000
Other 15 47.500000 2283.0800 2034.8300
---------------------------------------------------------
Total 8873 17647.000000 410228.0500 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 17891 208077.500000 791091.5000 791091.5000
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
132 933.000000 10085.9000 80.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 18023 209010.500000 801177.4000 791171.5000
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 7158 21359.750000 557199.5800 557199.5800
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
5509 4057.750000 157087.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 12667 25417.500000 714286.5800 557199.5800
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 3264 28840.000000 260191.3300 260191.3300
4069 2992.500000 123126.3000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 7444 32329.750000 389699.2700 265255.4700