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: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 1 1.000000 13.0500 13.0500
AUDE-92553-PURE TONE AUDIOMETRY AIR & BONE 1 1.000000 0.9900 0.9900
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 1 1.000000 9.1100 9.1100
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 1 1.000000 9.3400 9.3400
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 3 3.000000 47.6200 15.8733
AUDE-V5090-DISPENSING FEE PER HEARING AID 1 2.000000 230.0000 115.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 3 5.000000 375.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 2 4.000000 300.0000 75.0000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 33 58.500000 4387.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 4 6.268000 470.1000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 26 46.500000 3487.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 1 1.500000 83.2500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 2 4.000000 300.0000 75.0000
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 16 15.813000 766.4300 48.4683
PSTH-97001-EVAL BY LICENSED PT, INITIAL 7 7.000000 339.5000 48.5000
SPCH-92506-SPEECH EVAL BY LICENSED SLP 24 23.891800 1125.2500 47.0977
Subtotal (Total Children Is Unduplicated) 90 181.472800 11944.6400 65.8206
-----------------------------------------------------------------------------------------------------------------------
EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 12 70.000000 5158.1500 73.6879
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 1 20.000000 1000.0000 50.0000
EIIF-EIIF_NM-EI INDIVIDUAL SESSION BY NONMED PROF 1 1.000000 50.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 32 209.911000 10495.5500 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 108 429.815414 28828.5700 67.0720
OCCT-97530HM-OT SESSION BY OT ASST 5 31.000000 1599.4000 51.5935
PHY-97110-PT SESSION BY LICENSED PT 198 822.615984 55070.1400 66.9451
PHY-97110HM-PT SESSION BY PT ASST 8 20.704900 1124.6900 54.3200
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 221 892.557819 60330.8943 67.5933
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 2 3.000000 162.9600 54.3200
SPL-92508-GROUP SPL SESSION PER CHILD 1 3.000000 39.6000 13.2000
Subtotal (Total Children Is Unduplicated) 471 2503.605117 163859.9543 65.4496
-----------------------------------------------------------------------------------------------------------------------
Total 2685.077917 175804.5943 65.4747
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 528
-----------------------------------------------------------------------------------------------------------------------
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 1 1.000000 50.0000 50.0000
6 10.500000 762.5000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 7 11.500000 812.5000 50.0000
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
35 64.000000 2964.9500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 35 64.000000 2964.9500 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 38 130.000000 6803.9600 3082.9400
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 3 3.000000 185.7600 185.7600
T 0 0.000000 0.0000 0.0000
0 0.000000 0.0000 0.0000
Other 34 59.500000 3865.1600 1629.9400
---------------------------------------------------------
Total 75 192.500000 10854.8800 4898.6400
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 45 127.000000 7798.2800 7798.2800
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
323 613.750000 42208.2500 131.2000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 368 740.750000 50006.5300 7929.4800
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
380 702.250000 46704.9500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 380 702.250000 46704.9500 0.0000
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 1 1.000000 50.0000 50.0000
T 0 0.000000 0.0000 0.0000
23 21.922200 1389.4143 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 24 22.922200 1439.4143 50.0000
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
119 130.249000 8317.7700 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 119 130.249000 8317.7700 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 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
571 460.034417 30768.9800 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 571 460.034417 30768.9800 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 2 1.122300 54.4300 54.4300
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 7 11.000000 545.5000 545.5000
177 348.750000 23334.6900 23396.9100
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 186 360.872300 23934.6200 23996.8400