CMS/EIP Fiscal Report Statewide
Services beginning 10/01/2011 ending 12/31/2011 Date of Report:02/16/2012 Page: 1
List order: No List
Payclass Filters:TPIN
Eligibility Filter:Not Part C
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
CASE-CASE-NON-TCM CASE MANAGEMENT 1 0.500000 18.5000 37.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 2 2.250000 83.2500 37.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 4 11.500000 425.5000 37.0000
Subtotal (Total Children Is Unduplicated) 4 14.250000 527.2500 37.0000
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Screening, Eval, and Assessment,Class #02
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 4 4.000000 33.1200 8.2800
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 1 1.000000 10.3800 10.3800
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 5 5.000000 105.4000 21.0800
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 15 23.500000 1762.5000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 2 3.500000 262.5000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 3 4.500000 337.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 7 9.000000 675.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 11 18.500000 1026.7500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 166 266.706200 20002.9700 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 87 126.408000 9469.6400 74.9133
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 41 86.000000 6450.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 177 274.500000 15234.7500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 61 96.717460 7216.3095 74.6123
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 17 17.000000 3145.0000 185.0000
SCREEN-T1023-INTERDISCIPLINARY SCREENING 1 2.000000 100.0000 50.0000
Subtotal (Total Children Is Unduplicated) 336 938.331660 65831.8195 70.1584
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EI Services,Class #03
PHY-97110-PT SESSION BY LICENSED PT 1 1.000000 67.8800 67.8800
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 1 15.000000 7.5000 0.5000
Subtotal (Total Children Is Unduplicated) 2 16.000000 75.3800 4.7113
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Total 968.581660 66434.4495 68.5894
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Number of Children (Unduplicated) With at Least One Service 339
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Center 01
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 1 1.500000 112.5000 112.5000
D 21 28.500000 1708.5000 0.0000
S 0 0.000000 0.0000 0.0000
H 9 13.000000 975.0000 0.0000
T 0 0.000000 0.0000 0.0000
0 0.000000 0.0000 0.0000
Other 26 34.000000 2550.0000 0.0000
---------------------------------------------------------
Total 57 77.000000 5346.0000 112.5000
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
2 2.000000 100.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 2 2.000000 100.0000 0.0000
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
43 64.500000 4769.2500 0.0000
Other 10 10.000000 148.9000 0.0000
---------------------------------------------------------
Total 53 74.500000 4918.1500 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 23 20.500000 2054.0000 4319.9400
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
40 38.000000 3433.2500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 63 58.500000 5487.2500 4319.9400
Center 05
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
1 1.000000 64.0200 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 1 1.000000 64.0200 0.0000
Center 06
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
27 37.000000 2775.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 27 37.000000 2775.0000 0.0000
Center 07
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
2 2.000000 150.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 2 2.000000 150.0000 0.0000
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
194 332.000000 22823.2500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 194 332.000000 22823.2500 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 54 91.500000 6014.2500 3472.8400
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
63 106.000000 7023.7500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 117 197.500000 13038.0000 3472.8400
Center 51
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
4 27.500000 2043.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 4 27.500000 2043.0000 0.0000
Center 52
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 1 1.500000 112.5000 112.5000
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 3 5.500000 344.2500 0.0000
T 0 0.000000 0.0000 0.0000
6 11.000000 727.5000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 10 18.000000 1184.2500 112.5000
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 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
26 63.333200 3167.9900 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 26 63.333200 3167.9900 0.0000
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 1 0.384260 28.8195 28.8200
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
46 60.890000 4042.7700 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 47 61.274260 4071.5895 28.8200
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 1 1.500000 112.5000 0.0000
T 0 0.000000 0.0000 0.0000
12 14.474200 1085.5700 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 13 15.974200 1198.0700 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
1 1.000000 67.8800 67.8800
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 1 1.000000 67.8800 67.8800