CMS/EIP Fiscal Report Statewide
Services beginning 01/01/2014 ending 03/31/2014 Date of Report:06/03/2014 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 1733 1732.250000 64093.2500 37.0000
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 575 580.000000 0.0000 0.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 838 703.250000 25984.2500 36.9488
TCM-T1017TL-TARGETED CASE MANAGEMENT 5138 12617.75000 466819.7500 36.9971
TCON-TCON-TRANSITION CONFERENCE 62 63.000000 0.0000 0.0000
Subtotal (Total Children Is Unduplicated) 5371 15696.25000 556897.2500 35.4796
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Screening, Eval, and Assessment,Class #02
ASTE-ASTE-ASSISTIVE TECHNOLOGY EVAL 2 2.000000 97.0000 48.5000
AUDE-92552-PURE TONE AUDIOMETRY -AIR ONLY 4 4.000000 57.4400 14.3600
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 25 25.000000 250.5000 10.0200
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 16 17.000000 142.9700 8.4100
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 26 26.000000 546.0000 21.0000
AUDE-92585-AUD EVOKED RESPONSE (DIAG) 1 1.000000 62.6300 62.6300
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 4 4.000000 88.0800 22.0200
AUDE-V5010-ASSESSMENT FOR HEARING AID 1 2.000000 45.0000 22.5000
AUDE-V5090-DISPENSING FEE PER HEARING AID 2 4.000000 460.0000 115.0000
EVAL-EVAL-DEVELOPMENTAL EVALUATION 52 46.500000 2325.0000 50.0000
EXIT-EXIT-EXIT ASSESSMENT 170 194.250000 9712.5000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 19 24.000000 1800.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 4 4.000000 300.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 7 8.000000 600.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 26 35.000000 2625.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 36 41.500000 2303.2500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 351 468.000000 35100.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 93 133.000000 9975.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 171 216.500000 16237.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 573 751.500000 41708.2500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 325 405.500000 30412.5000 75.0000
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 84 84.000000 7982.8900 95.0344
MED-99204-OUTPATIENT VISIT, NEW, 45 MINS 2 2.000000 477.2700 238.6350
MED-99212-OUTPATIENT VISIT, EST, 10 MINS 1 1.000000 18.1700 18.1700
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 14 14.000000 793.9600 56.7114
MED-99214-OUTPATIENT VISIT, EST, 25 MINS 1 1.000000 48.2700 48.2700
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 14 14.000000 679.0000 48.5000
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 80 87.000000 4171.0000 47.9425
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 9 9.000000 436.5000 48.5000
PSTH-97001-EVAL BY LICENSED PT, INITIAL 58 58.000000 2813.0000 48.5000
SENS-V5014TS-HEARING AID REPAIR IN-OFFICE 1 1.000000 15.0000 15.0000
SPCH-92506-SPEECH EVAL BY LICENSED SLP 114 114.000000 5529.0000 48.5000
Subtotal (Total Children Is Unduplicated) 1220 2797.750000 177812.6800 63.5556
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 6 18.000000 8600.4400 477.8022
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 174 215.250000 10762.5000 50.0000
COIFP-COIFP-IFSP CONSULT, PRO, BY PHONE 12 4.500000 112.5000 25.0000
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 60 52.500000 2625.0000 50.0000
CONIP-CONIP-CONSULT, ITDS, PHONE 5 2.500000 62.5000 25.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 42 42.500000 2125.0000 50.0000
CONOP-CONOP-CONSULT, OT, PHONE 9 5.750000 143.7500 25.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 70 60.250000 3012.5000 50.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 178 169.250000 8462.5000 50.0000
CONSP-CONSP-CONSULT, SLP, PHONE 28 21.000000 525.0000 25.0000
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 107 3551.000000 88775.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 2866 15166.25000 758312.5000 50.0000
INTR-INTR-INTERPRETER 69 148.500000 7425.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 543 2114.500000 142066.9300 67.1870
OCCT-97530HM-OT SESSION BY OT ASST 44 189.250000 10225.7400 54.0330
PHY-97110-PT SESSION BY LICENSED PT 625 1948.500000 130149.1400 66.7945
PHY-97110HM-PT SESSION BY PT ASST 62 261.500000 14204.6800 54.3200
SENS-HA_EIP-ONE UNIT UP TO $500 PER AID 1 2.000000 1000.0000 500.0000
SENS-V5050-MED HEARING AID - ANALOG/DIGITAL 1 2.000000 456.0000 228.0000
SENS-V5264-EARMOLD 5 9.000000 162.0000 18.0000
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 970 3296.750000 222876.7700 67.6050
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 54 175.500000 9533.1600 54.3200
SPL-92508-GROUP SPL SESSION PER CHILD 7 26.000000 343.2000 13.2000
TRAN-TRAN-FAMILY TRANSPORTATION 284 288.000000 2304.0000 8.0000
TRAV-FLAT-PROV TRAVEL TO NATL ENV $10 PER CHILD 2419 15481.00000 154810.0000 10.0000
TRAV-TRAV-PROV TRAVEL TO NATURAL ENV PER MINUTE 1102 115372.0000 61868.2000 0.5362
Subtotal (Total Children Is Unduplicated) 4309 158623.2500 1640944.0100 10.3449
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Total 177117.250000 2375653.9400 13.4129
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Number of Children (Unduplicated) With at Least One Service 6480
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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
4 3.250000 1038.4900 1029.2400
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 4 3.250000 1038.4900 1029.2400
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
0 0.000000 0.0000 0.0000
Other 55 55.000000 814.9700 0.0000
---------------------------------------------------------
Total 55 55.000000 814.9700 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 77 89.250000 3867.7500 0.0000
P 5066 11197.250000 283446.7500 280027.1800
D 89 113.250000 4322.7500 0.0000
S 0 0.000000 0.0000 0.0000
H 1605 5224.000000 265396.3800 263148.9400
T 0 0.000000 0.0000 0.0000
3851 6639.500000 220447.5100 0.0000
Other 55 126.750000 8193.4500 7886.1000
---------------------------------------------------------
Total 10743 23390.000000 785674.5900 551062.2200
Center 09
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 2073 1998.750000 87876.9800 0.0000
P 5770 99045.750000 272473.2500 272473.2500
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 8 162.000000 1177.6600 1177.6600
845 2326.750000 126483.6800 135.7600
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 8696 103533.250000 488011.5700 273786.6700
Center 10
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 2811 2000.000000 83733.0000 0.0000
P 2543 7482.000000 202327.0800 202327.0800
D 0 0.000000 0.0000 0.0000
S 5 4.250000 157.2500 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
2582 3693.500000 187743.1000 0.0000
Other 1 0.250000 9.2500 0.0000
---------------------------------------------------------
Total 7942 13180.000000 473969.6800 202327.0800
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 22 20.500000 815.5000 815.5000
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
1 0.250000 9.2500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 23 20.750000 824.7500 815.5000
Center 57
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 44 46.500000 2859.7500 0.0000
P 2400 2081.000000 84969.0000 84969.0000
D 52 46.750000 1936.7500 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 2287 27335.250000 179458.5400 179458.5400
4364 7246.500000 354408.8700 207267.1800
Other 50 179.000000 1686.9800 1686.9800
---------------------------------------------------------
Total 9197 36935.000000 625319.8900 473381.7000