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
Agency Filter:EXT
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
TCM-T1017TL-TARGETED CASE MANAGEMENT 8 13.750000 508.7500 37.0000
Subtotal (Total Children Is Unduplicated) 8 13.750000 508.7500 37.0000
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Screening, Eval, and Assessment,Class #02
ASTE-ASTE-ASSISTIVE TECHNOLOGY EVAL 6 6.000000 291.0000 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) 40 42.000000 1027.7400 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 2 3.500000 175.0000 50.0000
EXIT-EXIT-EXIT ASSESSMENT 53 78.250000 3912.5000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 3 5.500000 412.5000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 2 3.500000 262.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 2 4.000000 300.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 1 2.000000 111.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 73 121.500000 9093.7500 74.8457
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 11 17.732000 1329.9000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 11 18.000000 1331.2500 73.9583
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 23 44.000000 2442.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 23 46.000000 3450.0000 75.0000
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 7 7.000000 293.1800 41.8829
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 96 95.187000 4553.8400 47.8410
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
SPCH-92506-SPEECH EVAL BY LICENSED SLP 91 90.108200 4328.2500 48.0339
Subtotal (Total Children Is Unduplicated) 423 829.277200 38446.2100 46.3611
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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 452 501.750000 25095.0000 50.0149
COIFP-COIFP-IFSP CONSULT, PRO, BY PHONE 35 21.750000 543.7500 25.0000
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 450 431.250000 21562.5000 50.0000
CONIP-CONIP-CONSULT, ITDS, PHONE 39 32.250000 806.2500 25.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 163 172.750000 8637.5000 50.0000
CONOP-CONOP-CONSULT, OT, PHONE 22 23.750000 593.7500 25.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 191 207.750000 10337.5000 49.7593
CONPP-CONPP-CONSULT, PT, PHONE 12 6.250000 156.2500 25.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 414 404.000000 20200.0000 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 11 52.000000 1300.0000 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 1294 10462.33900 518378.4500 49.5471
HERN-T1027SC-EI HEARING SERVICES AFTER SHINE 3 17.000000 850.0000 50.0000
INTR-INTR-INTERPRETER 56 730.500000 30692.7800 42.0161
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 406 2353.998423 152198.6700 64.6554
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
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 882 5616.178681 369091.6686 65.7194
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 3 222.000000 144.0000 0.6486
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 5884 1181365.000 613602.4000 0.5194
VISN-EIIF_NM-EI VISION SERVICES, IND NONMED 2 4.000000 200.0000 50.0000
Subtotal (Total Children Is Unduplicated) 6298 1205725.082 1979097.8486 1.6414
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Total 1206568.108790 2018052.8086 1.6726
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Number of Children (Unduplicated) With at Least One Service 6372
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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
1011 32638.000000 54790.8900 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 1960 66016.500000 107463.2700 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
5313 95048.250000 163616.0300 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 8459 154273.750000 254883.1000 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 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 6 186.000000 407.8800 407.8800
T 0 0.000000 0.0000 0.0000
15 13.000000 481.0000 0.0000
Other 9 18.000000 1202.4600 339.4000
---------------------------------------------------------
Total 3919 187542.000000 264297.7400 259984.6000
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 5845 226450.500000 452986.7000 452986.7000
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
179 4870.000000 14924.7900 233.5800
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 6024 231320.500000 467911.4900 453220.2800
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 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 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 6232 245557.750000 442928.5100 442928.5100
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 622 32232.250000 29173.7800 29173.7800
T 0 0.000000 0.0000 0.0000
88 2906.327700 3895.5390 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 710 35138.577700 33069.3190 29173.7800
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 988 45973.163000 42112.4100 42112.4100
T 0 0.000000 0.0000 0.0000
109 3910.538200 4729.4800 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 1097 49883.701200 46841.8900 42112.4100
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 1806 32014.666100 58694.4500 58694.4500
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 2900 50651.481734 91995.0696 91995.0700
33 83.304356 1606.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 4739 82749.452190 152295.5196 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 0 0.000000 0.0000 0.0000
P 0 0.000000 0.0000 0.0000
D 0 0.000000 0.0000 0.0000
S 110 5110.000000 6258.3200 6578.3200
H 0 0.000000 0.0000 0.0000
T 2938 148686.127700 241453.9000 242024.1400
10 289.750000 649.7500 622.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 3058 154085.877700 248361.9700 249224.4600