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
Agency Filter:EIP DEI DEIP
Payclass Filters:TPIN
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 3 1.250000 46.2500 37.0000
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 1 1.000000 0.0000 0.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 2 2.000000 74.0000 37.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 47 71.250000 2562.2500 35.9614
Subtotal (Total Children Is Unduplicated) 48 75.500000 2682.5000 35.5298
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Screening, Eval, and Assessment,Class #02
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 77 78.000000 645.8400 8.2800
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 48 49.000000 508.6200 10.3800
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 76 77.000000 1623.1600 21.0800
AUDE-92585-AUD EVOKED RESPONSE (DIAG) 1 1.000000 51.7600 51.7600
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 2 2.000000 54.3800 27.1900
AUDE-92588-OTOACOUSTIC EMISSIONS (COMP) 1 1.000000 30.3100 30.3100
BEHV-H0031HO-COMP BEHAVIORAL HEALTH ASSESSMENT 8 12.000000 1500.0000 125.0000
EXIT-EXIT-TRANSITION ASSESSMENT 4 4.500000 225.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 18 33.500000 2512.5000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 7 12.500000 937.5000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 3 5.000000 375.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 17 29.500000 2212.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 24 42.500000 2358.7500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 223 389.000000 29175.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 148 252.000000 18900.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 53 92.500000 6937.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 224 371.000000 20590.5000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 127 207.987999 15561.6000 74.8197
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 23 23.000000 4255.0000 185.0000
MED-99204-OUTPATIENT VISIT, NEW, 45 MINS 2 2.000000 114.5400 57.2700
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 2 2.000000 210.0000 105.0000
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 1 1.000000 48.5000 48.5000
PSTH-97001-EVAL BY LICENSED PT, INITIAL 1 1.000000 48.5000 48.5000
SCREEN-T1023-INTERDISCIPLINARY SCREENING 3 3.000000 150.0000 50.0000
SPCH-92506-SPEECH EVAL BY LICENSED SLP 1 1.000000 48.5000 48.5000
Subtotal (Total Children Is Unduplicated) 576 1692.987999 109074.9600 64.4275
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 3 5.500000 275.0000 50.0000
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 1 1.500000 75.0000 50.0000
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 1 7.000000 175.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 52 191.969800 9598.4900 50.0000
HERN-T1027SC-EI HEARING SERVICES AFTER SHINE 1 3.000000 150.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 9 19.250000 1306.6900 67.8800
PHY-97110-PT SESSION BY LICENSED PT 16 60.250000 4089.7700 67.8800
SHIN-T1027SC-INITIAL SHINE SERVICES, INDIVIDUAL 2 3.000000 150.0000 50.0000
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 17 85.000000 5769.8000 67.8800
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 1 1.000000 0.5000 0.5000
Subtotal (Total Children Is Unduplicated) 96 377.469800 21590.2500 57.1973
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Total 2145.957799 133347.7100 62.1390
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Number of Children (Unduplicated) With at Least One Service 701
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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 0 0.000000 0.0000 0.0000
D 73 94.500000 5574.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 40 52.000000 4275.0000 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 113 146.500000 9849.0000 0.0000
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
31 24.500000 869.5000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 31 24.500000 869.5000 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
107 158.000000 11567.3400 0.0000
Other 65 65.000000 994.0100 0.0000
---------------------------------------------------------
Total 172 223.000000 12561.3500 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 26 25.500000 2769.5000 4959.5700
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
60 64.000000 5333.7500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 86 89.500000 8103.2500 4959.5700
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
315 412.500000 22097.1000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 315 412.500000 22097.1000 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 5 8.000000 546.7600 546.7600
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
264 431.500000 29825.1000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 269 439.500000 30371.8600 546.7600
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 85 149.000000 10200.0000 5255.1600
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
144 254.000000 17151.3800 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 229 403.000000 27351.3800 5255.1600
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
2 2.000000 130.5000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 2 2.000000 130.5000 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 0 0.000000 0.0000 0.0000
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 36 67.750000 4397.6900 0.0000
T 0 0.000000 0.0000 0.0000
38 69.500000 3874.9900 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 74 137.250000 8272.6800 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 5 2.750000 137.5000 137.5000
D 11 7.250000 330.0000 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
76 101.750000 5354.5000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 92 111.750000 5822.0000 137.5000
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 2 1.000000 50.0000 50.0000
D 1 1.000000 50.0000 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
162 141.469800 7015.9900 110.9900
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 165 143.469800 7115.9900 160.9900
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 2 2.487999 186.6000 74.1000
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 2 3.000000 225.0000 0.0000
T 0 0.000000 0.0000 0.0000
11 7.500000 391.5000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 15 12.987999 803.1000 74.1000