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
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 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 1881 4425.500000 163706.5000 36.9916
TCON-TCON-TRANSITION CONFERENCE 62 63.000000 0.0000 0.0000
Subtotal (Total Children Is Unduplicated) 3542 7504.000000 253784.0000 33.8198
-----------------------------------------------------------------------------------------------------------------------
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) 6 6.000000 60.1200 10.0200
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 6 6.000000 50.4600 8.4100
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 7 7.000000 147.0000 21.0000
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 4 4.000000 88.0800 22.0200
AUDE-V5010-ASSESSMENT FOR HEARING AID 1 1.000000 9.0800 9.0800
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 5 6.000000 450.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 3 3.000000 225.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 5 6.000000 450.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 6 7.000000 388.5000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 85 97.500000 7312.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 12 18.000000 1350.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 21 18.500000 1387.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 135 170.500000 9462.7500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 74 88.500000 6637.5000 75.0000
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 62 62.000000 2511.0000 40.5000
MED-99204-OUTPATIENT VISIT, NEW, 45 MINS 1 1.000000 57.2700 57.2700
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 10 10.000000 221.4000 22.1400
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 5 5.000000 242.5000 48.5000
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 46 46.000000 2198.4000 47.7913
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 1 1.000000 48.5000 48.5000
PSTH-97001-EVAL BY LICENSED PT, INITIAL 25 25.000000 1212.5000 48.5000
SENS-V5014TS-HEARING AID REPAIR IN-OFFICE 1 1.000000 15.0000 15.0000
SPCH-92506-SPEECH EVAL BY LICENSED SLP 57 56.000000 2716.0000 48.5000
Subtotal (Total Children Is Unduplicated) 598 896.750000 49893.0000 55.6376
-----------------------------------------------------------------------------------------------------------------------
EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 6 11.000000 4568.9900 415.3627
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 19 14.500000 725.0000 50.0000
CONIP-CONIP-CONSULT, ITDS, PHONE 4 2.000000 50.0000 25.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 25 26.000000 1300.0000 50.0000
CONOP-CONOP-CONSULT, OT, PHONE 5 2.250000 56.2500 25.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 44 38.750000 1937.5000 50.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 143 138.750000 6937.5000 50.0000
CONSP-CONSP-CONSULT, SLP, PHONE 14 7.000000 175.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 843 4342.500000 217125.0000 50.0000
INTR-INTR-INTERPRETER 69 148.500000 7425.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 284 995.500000 66522.4000 66.8231
OCCT-97530HM-OT SESSION BY OT ASST 32 135.500000 7333.6000 54.1225
PHY-97110-PT SESSION BY LICENSED PT 285 799.750000 52782.1400 65.9983
PHY-97110HM-PT SESSION BY PT ASST 17 86.000000 4671.5200 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 584 1873.250000 126484.9700 67.5217
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 42 139.500000 7577.6400 54.3200
TRAN-TRAN-FAMILY TRANSPORTATION 284 288.000000 2304.0000 8.0000
TRAV-FLAT-PROV TRAVEL TO NATL ENV $10 PER CHILD 2416 15441.00000 154410.0000 10.0000
TRAV-TRAV-PROV TRAVEL TO NATURAL ENV PER MINUTE 150 28717.00000 18519.3000 0.6449
Subtotal (Total Children Is Unduplicated) 3542 53439.50000 693398.8100 12.9754
-----------------------------------------------------------------------------------------------------------------------
Total 61840.250000 997075.8100 16.1234
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 5250
-----------------------------------------------------------------------------------------------------------------------
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 5 5.000000 70.4500 0.0000
---------------------------------------------------------
Total 5 5.000000 70.4500 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 2584 8106.250000 163286.5200 161126.4000
D 89 113.250000 4322.7500 0.0000
S 0 0.000000 0.0000 0.0000
H 12 38.000000 965.7800 965.7800
T 0 0.000000 0.0000 0.0000
2960 2707.250000 84131.1700 0.0000
Other 12 29.000000 1877.6200 1979.4400
---------------------------------------------------------
Total 5657 10993.750000 254583.8400 164071.6200
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 4200 12650.250000 224226.7500 224226.7500
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 5 18.000000 1105.6600 1105.6600
3 5.000000 339.4000 135.7600
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 4208 12673.250000 225671.8100 225468.1700
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 2543 7482.000000 202327.0800 202327.0800
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
1668 1205.500000 46689.5000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 4211 8687.500000 249016.5800 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 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
1 0.250000 9.2500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 1 0.250000 9.2500 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 3 4.250000 157.2500 157.2500
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 2271 27298.750000 177544.2000 177544.2000
2870 2127.500000 87047.1900 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 5196 29477.250000 266685.3900 177701.4500