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
Payclass Filters:GR
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 4657.250000 172188.7500 36.9722
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 2087 2335.000000 0.0000 0.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 2510 2460.750000 90992.2500 36.9774
TCM-T1017TL-TARGETED CASE MANAGEMENT 2964 8935.500000 330252.7500 36.9596
TCON-TCON-TRANSITION CONFERENCE 404 405.000000 0.0000 0.0000
Subtotal (Total Children Is Unduplicated) 7219 18793.50000 593433.7500 31.5765
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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 44 45.000000 587.2500 13.0500
AUDE-92553-PURE TONE AUDIOMETRY AIR & BONE 4 4.000000 66.1300 16.5325
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 46 48.000000 437.2800 9.1100
AUDE-92557-COMP AUDIO THRESHOLD EVAL/SPCH RECOG 1 1.000000 23.4500 23.4500
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 50 53.000000 495.0200 9.3400
AUDE-92568-ACOUSTIC REFLEX TESTING (MEMR) 1 1.000000 7.9300 7.9300
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 50 52.000000 1125.8000 21.6500
AUDE-92585-AUD EVOKED RESPONSE (DIAG) 1 1.000000 56.9400 56.9400
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 41 43.000000 1052.2100 24.4700
AUDE-V5010-ASSESSMENT FOR HEARING AID 2 2.000000 90.0000 45.0000
AUDE-V5090-DISPENSING FEE PER HEARING AID 3 6.000000 690.0000 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 17 24.500000 1837.5000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 5 6.500000 487.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 13 14.500000 1087.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 13 22.000000 1221.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 197 287.000000 21506.2500 74.9347
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 59 97.232000 7292.4000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 39 49.500000 3693.7500 74.6212
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 275 454.500000 25224.7500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 190 204.500000 15337.5000 75.0000
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 4 4.000000 182.2600 45.5650
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 7 7.000000 293.1800 41.8829
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 97 96.187000 4602.3400 47.8478
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 4 4.000000 194.0000 48.5000
PSTH-97001-EVAL BY LICENSED PT, INITIAL 28 28.000000 1358.0000 48.5000
SCREEN-T1023-SCREENING 2 2.000000 100.0000 50.0000
SPCH-92506-SPEECH EVAL BY LICENSED SLP 99 98.108200 4716.2500 48.0719
Subtotal (Total Children Is Unduplicated) 1194 2339.277200 127941.6900 54.6928
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 19 66.000000 5073.9300 76.8777
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 488 496.000000 24787.5000 49.9748
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 496 493.000000 24650.0000 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-T1027TTSC-EI GROUP SESSION BY EI PROF 13 55.000000 1375.0000 25.0000
EIIF-96154-HEALTH AND BEHAVIOR INTERVENTION 1 9.000000 450.0000 50.0000
EIIF-EIIF_NM-EI INDIVIDUAL SESSION BY NONMED PROF 2 4.000000 200.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 1359 10721.69060 531346.0300 49.5580
HERN-T1027SC-EI HEARING SERVICES AFTER SHINE 4 18.000000 900.0000 50.0000
INTR-INTR-INTERPRETER 167 913.750000 39855.2800 43.6173
OCCT-97530-OT SESSION BY LICENSED OT 441 2735.520386 180703.3600 66.0581
OCCT-97530HM-OT SESSION BY OT ASST 27 113.500000 6021.0000 53.0485
PHY-97110-PT SESSION BY LICENSED PT 412 2376.998423 153759.9100 64.6866
PHY-97110HM-PT SESSION BY PT ASST 19 45.045100 2420.4100 53.7330
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 2 2.000000 100.0000 50.0000
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 911 5801.178681 381649.4686 65.7883
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 20 80.500000 4372.7600 54.3200
SPL-92508-GROUP SPL SESSION PER CHILD 2 2.000000 26.4000 13.2000
TRAN-TRAN-FAMILY TRANSPORTATION 326 551.000000 2776.0000 5.0381
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 6267 1247605.000 646644.4000 0.5183
VISN-EIIF_NM-EI VISION SERVICES, IND NONMED 2 4.000000 200.0000 50.0000
Subtotal (Total Children Is Unduplicated) 6788 1273299.433 2068458.4686 1.6245
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Total 1294432.210390 2789833.9086 2.1553
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Number of Children (Unduplicated) With at Least One Service 9692
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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 949 33378.500000 52672.3800 52672.3800
2588 33439.250000 84159.6400 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 3537 66817.750000 136832.0200 52672.3800
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 3146 59225.500000 91267.0700 91267.0700
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
12494 105078.750000 285667.0300 0.0000
Other 1 1.000000 24.4700 0.0000
---------------------------------------------------------
Total 15641 164305.250000 376958.5700 91267.0700
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 3889 187325.000000 262206.4000 259237.3200
D 21 27.250000 1008.2500 249.7500
S 0 0.000000 0.0000 0.0000
H 6 186.000000 407.8800 407.8800
T 0 0.000000 0.0000 0.0000
2963 2510.250000 76269.7600 0.0000
Other 9 18.000000 1202.4600 339.4000
---------------------------------------------------------
Total 6888 190066.500000 341094.7500 260234.3500
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 15395 251977.250000 681640.4800 681640.4800
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
288 5427.250000 17606.8300 233.5800
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 15683 257404.500000 699247.3100 681874.0600
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 6232 245557.750000 442928.5100 442928.5100
D 2 1.000000 37.0000 37.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
4515 3266.500000 123944.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 10749 248825.250000 566909.5100 442965.5100
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 2305 53740.236000 75047.8300 75006.8300
T 0 0.000000 0.0000 0.0000
117 3101.327700 4735.5390 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 2422 56841.563700 79783.3690 75006.8300
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 3 1.250000 46.2500 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
109 3910.538200 4729.4800 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 2692 70387.066800 88415.5600 83639.8300
Center 55
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 2 1.500000 55.5000 0.0000
P 1806 32014.666100 58694.4500 58694.4500
D 39 47.500000 2518.5000 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 2900 50651.481734 91995.0696 91995.0700
1628 1347.554356 33319.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 6375 84062.702190 186582.5196 150689.5200
Center 57
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 1 1.000000 37.0000 0.0000
P 1 1.250000 46.2500 46.2500
D 6 6.750000 249.7500 0.0000
S 110 5110.000000 6258.3200 6578.3200
H 0 0.000000 0.0000 0.0000
T 2941 148826.127700 241527.9000 242098.1400
1668 1776.500000 65891.0800 622.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 4727 155721.627700 314010.3000 249344.7100