CMS/EIP Fiscal Report Statewide
Services beginning 07/01/2012 ending 09/30/2012 Date of Report:11/16/2012 Page: 1
List order: No List
Agency Filter:EXT
Payclass Filters:TPIN
Eligibility Filter:Part C (excluding not eligible)
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Screening, Eval, and Assessment,Class #02
AUDE-92552-PURE TONE AUDIOMETRY -AIR ONLY 2 2.000000 13.0700 6.5350
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 1 1.000000 9.1100 9.1100
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 2 2.000000 13.7200 6.8600
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 2 3.000000 62.7500 20.9167
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 1 1.000000 24.4700 24.4700
AUDE-V5090-DISPENSING FEE PER HEARING AID 1 2.000000 230.0000 115.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 13 22.000000 1654.5600 75.2073
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 4 7.500000 562.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 3 4.500000 337.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 2 2.000000 141.7800 70.8900
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 94 161.071400 12080.3700 75.0001
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 12 20.214400 1516.0800 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 38 60.388933 4529.1700 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 17 30.500000 1692.7500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 18 30.500000 2287.5000 75.0000
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 2 2.000000 97.0000 48.5000
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 12 13.000000 607.0000 46.6923
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 2 2.000000 97.0000 48.5000
PSTH-97001-EVAL BY LICENSED PT, INITIAL 11 11.000000 533.5000 48.5000
SPCH-92506-SPEECH EVAL BY LICENSED SLP 33 31.999999 1552.0000 48.5000
Subtotal (Total Children Is Unduplicated) 206 409.674732 28041.8300 68.4490
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 11 41.000000 20883.7800 509.3605
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 1 1.000000 50.0000 50.0000
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 1 1.000000 50.0000 50.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 1 1.000000 50.0000 50.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 1 1.000000 50.0000 50.0000
EIIF-96154-HEALTH AND BEHAVIOR INTERVENTION 16 146.500000 7328.6100 50.0246
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 129 484.629800 24393.1200 50.3335
OCCT-97530-OT SESSION BY LICENSED OT 143 589.859422 39733.4900 67.3609
OCCT-97530HM-OT SESSION BY OT ASST 10 37.750000 2046.2600 54.2056
PHY-97110-PT SESSION BY LICENSED PT 222 945.880371 63890.5100 67.5461
PHY-97110HM-PT SESSION BY PT ASST 8 22.500000 1240.4800 55.1324
SENS-HA_EIP-ONE UNIT UP TO $500 PER AID 1 2.000000 1000.0000 500.0000
SHIN-T1027SC-INITIAL SHINE SERVICES, INDIVIDUAL 1 5.000000 250.0000 50.0000
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 315 1454.902987 98863.8580 67.9522
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 6 9.000000 488.8800 54.3200
SPL-92508-GROUP SPL SESSION PER CHILD 2 12.500000 165.0000 13.2000
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 5 188.000000 100.9000 0.5367
Subtotal (Total Children Is Unduplicated) 703 3943.522580 260584.8880 66.0792
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Total 4353.197312 288626.7180 66.3022
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Number of Children (Unduplicated) With at Least One Service 847
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Center 01
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 24 51.000000 2710.9200 2710.9200
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
369 438.500000 45236.3300 0.0000
Other 105 150.500000 10516.5800 0.0000
---------------------------------------------------------
Total 498 640.000000 58463.8300 2710.9200
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
7 12.500000 937.5000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 7 12.500000 937.5000 0.0000
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
17 17.000000 1028.8000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 17 17.000000 1028.8000 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 11 38.000000 2132.4400 892.4300
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 3 8.500000 451.8200 351.8200
T 0 0.000000 0.0000 0.0000
0 0.000000 0.0000 0.0000
Other 47 96.000000 6064.0200 5139.9000
---------------------------------------------------------
Total 61 142.500000 8648.2800 6384.1500
Center 07
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 19 63.250000 3323.4200 3323.4200
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
142 433.250000 24908.5000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 161 496.500000 28231.9200 3323.4200
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 58 158.000000 10295.9200 11420.3000
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
411 689.750000 47097.1700 48.8800
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 469 847.750000 57393.0900 11469.1800
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
331 690.250000 41169.0900 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 331 690.250000 41169.0900 0.0000
Center 51
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 6 35.000000 1821.5200 1821.5200
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
42 103.000000 6696.2000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 48 138.000000 8517.7200 1821.5200
Center 53
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 2 2.000000 100.0000 100.0000
T 0 0.000000 0.0000 0.0000
165 160.276476 9048.8739 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 167 162.276476 9148.8739 100.0000
Center 54
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
376 405.512100 22158.1741 0.0000
Other 1 1.000000 67.8800 0.0000
---------------------------------------------------------
Total 377 406.512100 22226.0541 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 6 6.000000 407.2800 407.2800
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 1 1.500000 112.5000 0.0000
T 3 3.000000 203.6400 203.6400
483 447.012850 29524.6300 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 493 457.512850 30248.0500 610.9200
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 4 6.645886 431.7400 431.7400
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 6 20.500000 1176.9800 1176.9800
159 315.250000 21004.7900 21004.7900
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 169 342.395886 22613.5100 22613.5100