CMS/EIP Fiscal Report Statewide
Services beginning 10/01/2012 ending 12/31/2012 Date of Report:02/16/2013 Page: 1
List order: No List
Eligibility Filter:Part C (excluding not eligible)
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
CASE-CASE-NON-TCM CASE MANAGEMENT 3903 4658.000000 172216.5000 36.9722
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 2088 2336.000000 0.0000 0.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 2511 2462.750000 91066.2500 36.9775
TCM-T1017TL-TARGETED CASE MANAGEMENT 9254 27302.00000 1009295.0000 36.9678
TCON-TCON-TRANSITION CONFERENCE 404 405.000000 0.0000 0.0000
Subtotal (Total Children Is Unduplicated) 10051 37163.75000 1272577.7500 34.2424
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Screening, Eval, and Assessment,Class #02
ASTE-ASTE-ASSISTIVE TECHNOLOGY EVAL 8 8.000000 388.0000 48.5000
AUDE-92552-PURE TONE AUDIOMETRY -AIR ONLY 46 47.000000 613.3500 13.0500
AUDE-92553-PURE TONE AUDIOMETRY AIR & BONE 4 5.000000 67.1200 13.4240
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 89 92.000000 838.1200 9.1100
AUDE-92557-COMP AUDIO THRESHOLD EVAL/SPCH RECOG 1 1.000000 23.4500 23.4500
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 68 71.000000 663.1400 9.3400
AUDE-92568-ACOUSTIC REFLEX TESTING (MEMR) 1 1.000000 7.9300 7.9300
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 97 101.000000 2173.0000 21.5149
AUDE-92585-AUD EVOKED RESPONSE (DIAG) 1 1.000000 56.9400 56.9400
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 43 45.000000 1101.1500 24.4700
AUDE-V5010-ASSESSMENT FOR HEARING AID 2 2.000000 90.0000 45.0000
AUDE-V5090-DISPENSING FEE PER HEARING AID 4 8.000000 920.0000 115.0000
EVAL-EVAL-DEVELOPMENTAL EVALUATION 79 87.000000 4350.0000 50.0000
EXIT-EXIT-EXIT ASSESSMENT 370 588.750000 29437.5000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 99 167.000000 12525.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 36 58.500000 4387.5000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 24 38.500000 2887.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 55 93.500000 7012.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 106 178.000000 9879.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 815 1282.000000 96131.2500 74.9854
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 340 585.500000 43912.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 310 460.500000 34518.7500 74.9593
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 1230 1987.500000 110306.2500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 534 709.500000 53212.5000 75.0000
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 126 126.000000 11175.8900 88.6975
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 23 23.000000 1486.0800 64.6122
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 17 18.000000 826.6800 45.9267
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 149 150.000000 7211.7700 48.0785
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 12 12.000000 582.0000 48.5000
PSTH-97001-EVAL BY LICENSED PT, INITIAL 64 64.000000 3104.0000 48.5000
SCREEN-T1023-SCREENING 3 3.000000 150.0000 50.0000
SPCH-92506-SPEECH EVAL BY LICENSED SLP 168 174.000000 8363.5000 48.0661
Subtotal (Total Children Is Unduplicated) 2508 7188.250000 448402.3700 62.3799
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 24 136.000000 10232.0800 75.2359
AUD-HA_FUP-AUDIOLOGY SERVICES 1 1.000000 50.0000 50.0000
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 532 626.500000 31332.5000 50.0120
COIFP-COIFP-IFSP CONSULT, PRO, BY PHONE 45 27.250000 681.2500 25.0000
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 490 516.500000 25812.5000 49.9758
CONIP-CONIP-CONSULT, ITDS, PHONE 41 34.000000 850.0000 25.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 191 202.500000 10125.0000 50.0000
CONOP-CONOP-CONSULT, OT, PHONE 22 23.750000 593.7500 25.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 230 239.750000 11937.5000 49.7914
CONPP-CONPP-CONSULT, PT, PHONE 14 7.500000 187.5000 25.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 497 494.000000 24700.0000 50.0000
CONSP-CONSP-CONSULT, SLP, PHONE 37 19.000000 475.0000 25.0000
COUN-H2019HR-INDIVIDUAL/FAMILY THERAPY 9 11.000000 806.5200 73.3200
EIGF-EIGF_NM-EI GROUP SESSION BY NONMED PROF 4 632.000000 15800.0000 25.0000
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 122 3906.000000 97650.0000 25.0000
EIIF-96154-HEALTH AND BEHAVIOR INTERVENTION 1 9.000000 450.0000 50.0000
EIIF-EIIF_NM-EI INDIVIDUAL SESSION BY NONMED PROF 3 11.000000 550.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 4227 32479.00000 1619161.5000 49.8526
HERN-T1027SC-EI HEARING SERVICES AFTER SHINE 13 30.000000 1500.0000 50.0000
INTR-INTR-INTERPRETER 167 913.750000 39855.2800 43.6173
OCCT-97530-OT SESSION BY LICENSED OT 879 5429.500000 363104.6100 66.8763
OCCT-97530HM-OT SESSION BY OT ASST 43 207.000000 11015.4000 53.2145
PHY-97110-PT SESSION BY LICENSED PT 1074 5895.250007 391809.8000 66.4619
PHY-97110HM-PT SESSION BY PT ASST 56 229.250000 12426.4200 54.2047
SENS-HA_EIP-ONE UNIT UP TO $500 PER AID 4 8.000000 4000.0000 500.0000
SENS-V5264-EARMOLD 3 6.000000 108.0000 18.0000
SHIN-T1027SC-INITIAL SHINE SERVICES, INDIVIDUAL 7 8.000000 400.0000 50.0000
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 1666 10137.98650 675666.6929 66.6470
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 25 90.000000 4888.8000 54.3200
SPL-92508-GROUP SPL SESSION PER CHILD 9 12.250000 161.7000 13.2000
TRAN-TRAN-FAMILY TRANSPORTATION 326 551.000000 2776.0000 5.0381
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 6269 1247867.000 646775.4000 0.5183
VISN-EIIF_NM-EI VISION SERVICES, IND NONMED 2 4.000000 200.0000 50.0000
Subtotal (Total Children Is Unduplicated) 7291 1310764.737 4006083.2029 3.0563
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Total 1355116.736507 5727063.3229 4.2263
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Number of Children (Unduplicated) With at Least One Service 11219
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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 683 449.250000 16391.0000 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 950 33379.500000 52722.3800 52722.3800
2913 33787.750000 102854.3900 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 4546 67616.500000 171967.7700 52722.3800
Center 03
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 12 7.500000 277.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 313 227.250000 9754.2500 0.0000
P 4934 60203.250000 130493.5700 130522.8200
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 0 0.000000 0.0000 0.0000
12581 105222.750000 294512.9200 0.0000
Other 105 105.000000 1558.8500 0.0000
---------------------------------------------------------
Total 17945 165765.750000 436597.0900 130522.8200
Center 04
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 23 31.750000 1174.7500 0.0000
U 0 0.000000 0.0000 0.0000
B 925 1100.500000 42436.7500 0.0000
P 6187 189982.500000 365291.4900 358360.0600
D 22 27.750000 1026.7500 249.7500
S 0 0.000000 0.0000 0.0000
H 2141 7325.000000 361215.2800 360811.3000
T 0 0.000000 0.0000 0.0000
4183 7531.750000 259430.3000 0.0000
Other 49 87.250000 5564.8900 2290.8600
---------------------------------------------------------
Total 13530 206086.500000 1036140.2100 721711.9700
Center 09
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 2 2.500000 92.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 5421 5261.750000 228339.2600 0.0000
P 15461 252129.500000 690948.4100 690948.4100
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
2864 12003.250000 399063.1900 364.7800
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 23748 269397.000000 1318443.3600 691313.1900
Center 10
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 220 120.750000 4467.7500 0.0000
U 0 0.000000 0.0000 0.0000
B 7459 5101.500000 213632.0000 0.0000
P 6242 245575.250000 444116.8900 444049.0100
D 2 1.000000 37.0000 37.0000
S 1 0.250000 9.2500 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
7256 10370.500000 530251.7300 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 21180 261169.250000 1192514.6200 444086.0100
Center 53
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 2 2.250000 159.2500 0.0000
P 1063 965.264000 40123.2000 40263.5500
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 2306 53741.236000 75097.8300 75056.8300
T 0 0.000000 0.0000 0.0000
889 3967.249900 46472.3033 0.0000
Other 13 13.000000 650.0000 0.0000
---------------------------------------------------------
Total 4273 58688.999900 162502.5833 115320.3800
Center 54
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 179 181.000000 9725.6600 0.0000
P 1320 861.522800 34530.8900 34772.8500
D 4 1.750000 64.7500 0.0000
S 0 0.000000 0.0000 0.0000
H 2580 66475.278600 83639.8300 83639.8300
T 0 0.000000 0.0000 0.0000
1467 5240.448600 78088.8700 0.0000
Other 12 12.250000 662.5000 0.0000
---------------------------------------------------------
Total 5562 72772.250000 206712.5000 118412.6800
Center 55
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 41 43.000000 1591.0000 0.0000
P 3437 33548.666100 118232.2000 118232.2000
D 39 47.500000 2518.5000 0.0000
S 4 3.500000 129.5000 0.0000
H 1 1.500000 112.5000 0.0000
T 2900 50651.481734 91995.0696 91995.0700
4329 3734.588773 184351.2200 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 10751 88030.236607 398929.9896 210227.2700
Center 57
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 2 1.000000 37.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 1115 1046.500000 43528.2500 0.0000
P 828 900.122300 40568.4300 40568.4300
D 6 6.750000 249.7500 0.0000
S 112 5131.000000 6318.3200 6638.3200
H 5 7.750000 495.7500 0.0000
T 2951 148846.127700 242523.4000 243093.6400
3842 9485.000000 469079.9600 309501.8900
Other 12 166.000000 454.3400 454.3400
---------------------------------------------------------
Total 8873 165590.250000 803255.2000 600256.6200