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: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 4 4.750000 175.7500 37.0000
Subtotal (Total Children Is Unduplicated) 4 4.750000 175.7500 37.0000
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Screening, Eval, and Assessment,Class #02
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 25 26.000000 248.6900 9.5650
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 11 11.000000 97.1600 8.8327
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 25 26.000000 555.4900 21.3650
AUDE-92585-AUD EVOKED RESPONSE (DIAG) 1 1.000000 56.9400 56.9400
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 2 2.000000 46.4900 23.2450
EVAL-EVAL-DEVELOPMENTAL EVALUATION 1 4.000000 200.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 25 45.500000 3412.5000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 6 7.500000 562.5000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 7 12.500000 937.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 27 40.000000 3000.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 16 24.500000 1359.7500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 271 453.000000 33937.5000 74.9172
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 125 192.000000 14400.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 132 217.000000 16275.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 226 380.000000 21090.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 239 339.500000 25425.0000 74.8895
MED-99202-OUTPATIENT VISIT, NEW, 20 MINS 3 3.000000 570.0000 190.0000
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 39 39.000000 10920.0000 280.0000
MED-99204-OUTPATIENT VISIT, NEW, 45 MINS 1 1.000000 420.0000 420.0000
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 8 8.000000 1440.0000 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 7 7.000000 339.5000 48.5000
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 1 1.000000 48.5000 48.5000
PSTH-97001-EVAL BY LICENSED PT, INITIAL 12 12.000000 582.0000 48.5000
SPCH-92506-SPEECH EVAL BY LICENSED SLP 13 13.000000 630.5000 48.5000
Subtotal (Total Children Is Unduplicated) 653 1866.500000 136603.5200 73.1870
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 16 108.000000 5400.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 64 343.750000 22316.1000 64.9196
OCCT-97530HM-OT SESSION BY OT ASST 5 18.000000 847.3800 47.0767
PHY-97110-PT SESSION BY LICENSED PT 140 635.000000 42458.4000 66.8636
PHY-97110HM-PT SESSION BY PT ASST 8 28.500000 1548.1200 54.3200
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 166 848.750000 57012.0100 67.1717
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 1 0.500000 27.1600 54.3200
TRAV-FLAT-PROV TRAVEL TO NATL ENV $10 PER CHILD 1 1.000000 10.0000 10.0000
Subtotal (Total Children Is Unduplicated) 334 1983.500000 129619.1700 65.3487
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Total 3854.750000 266398.4400 69.1091
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Number of Children (Unduplicated) With at Least One Service 933
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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
121 168.250000 12277.1900 0.0000
Other 66 66.000000 1004.7700 0.0000
---------------------------------------------------------
Total 187 234.250000 13281.9600 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 44 62.000000 5957.6600 7184.0800
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 2 7.000000 421.5200 150.0000
T 0 0.000000 0.0000 0.0000
110 97.500000 14350.5000 0.0000
Other 83 195.500000 12766.0800 7549.7300
---------------------------------------------------------
Total 239 362.000000 33495.7600 14883.8100
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 10 43.000000 2579.1200 2579.1200
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
812 1416.250000 97115.8000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 822 1459.250000 99694.9200 2579.1200
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
702 1302.500000 86567.4600 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 702 1302.500000 86567.4600 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 1 1.500000 112.5000 58.4100
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 17 25.500000 1912.5000 0.0000
T 0 0.000000 0.0000 0.0000
61 98.250000 7057.5000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 79 125.250000 9082.5000 58.4100
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 1.500000 101.8200 101.8200
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 7 33.500000 1826.9800 1826.9800
174 336.500000 22347.0400 22180.5400
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 182 371.500000 24275.8400 24109.3400