CMS/EIP Fiscal Report Statewide
Services beginning 01/01/2013 ending 03/31/2013 Date of Report:05/17/2013 Page: 1
List order: No List
Agency Filter:EXT
Payclass Filters:MED
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 43 64.750000 2395.7500 37.0000
Subtotal (Total Children Is Unduplicated) 43 64.750000 2395.7500 37.0000
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Screening, Eval, and Assessment,Class #02
AUDE-92552-PURE TONE AUDIOMETRY -AIR ONLY 3 3.000000 39.1500 13.0500
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 3 3.000000 27.3300 9.1100
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 1 1.000000 9.3400 9.3400
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 2 2.000000 43.4600 21.7300
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 1 1.000000 24.4700 24.4700
AUDE-92588-OTOACOUSTIC EMISSIONS (COMP) 2 2.000000 54.5600 27.2800
AUDE-V5090-DISPENSING FEE PER HEARING AID 1 2.000000 230.0000 115.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 9 15.000000 1125.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 5 9.000000 675.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 1 2.000000 150.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 2 4.000000 222.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 87 151.000000 11325.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 26 47.500000 3562.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 8 12.000000 900.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 11 19.000000 1054.5000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 16 30.000000 2250.0000 75.0000
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 13 14.000000 679.0000 48.5000
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 48 48.000000 2328.0000 48.5000
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 7 7.000000 339.5000 48.5000
PSTH-97001-EVAL BY LICENSED PT, INITIAL 32 33.000000 1600.5000 48.5000
SPCH-92506-SPEECH EVAL BY LICENSED SLP 47 47.000000 2279.5000 48.5000
Subtotal (Total Children Is Unduplicated) 236 452.500000 28918.8100 63.9090
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 2370 19921.75000 996087.5000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 306 1655.500000 112375.3400 67.8800
OCCT-97530HM-OT SESSION BY OT ASST 16 51.250000 2783.9000 54.3200
PHY-97110-PT SESSION BY LICENSED PT 343 1924.750000 130652.0300 67.8800
PHY-97110HM-PT SESSION BY PT ASST 43 226.000000 12276.3200 54.3200
SENS-V5050-MED HEARING AID - ANALOG/DIGITAL 1 2.000000 456.0000 228.0000
SENS-V5264-EARMOLD 1 2.000000 36.0000 18.0000
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 416 2380.250000 161571.3700 67.8800
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 2 8.500000 461.7200 54.3200
SPL-92508-GROUP SPL SESSION PER CHILD 25 45.250000 597.3000 13.2000
Subtotal (Total Children Is Unduplicated) 2998 26217.25000 1417297.4800 54.0597
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Total 26734.500000 1448612.0400 54.1851
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Number of Children (Unduplicated) With at Least One Service 3134
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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 0 0.000000 0.0000 0.0000
77 144.500000 10457.2500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 77 144.500000 10457.2500 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 40 31.750000 1174.7500 0.0000
P 36 33.000000 1221.0000 1221.0000
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 2320 7477.500000 378441.5400 348018.1600
T 0 0.000000 0.0000 0.0000
222 409.250000 26907.7900 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 2618 7951.500000 407745.0800 349239.1600
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 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
1869 5455.500000 301133.5200 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 1869 5455.500000 301133.5200 0.0000
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 6 9.000000 467.8800 100.0000
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
2165 6059.750000 329580.9600 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 2171 6068.750000 330048.8400 100.0000
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
2039 1804.250000 114348.7800 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 2039 1804.250000 114348.7800 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 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
1593 5310.000000 284878.5700 284878.5700
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 1593 5310.000000 284878.5700 284878.5700