CMS/EIP Fiscal Report Statewide
Services beginning 01/01/2012 ending 03/31/2012 Date of Report:05/16/2012 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
TCM-T1017TL-TARGETED CASE MANAGEMENT 4 19.250000 712.2500 37.0000
Subtotal (Total Children Is Unduplicated) 4 19.250000 712.2500 37.0000
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Screening, Eval, and Assessment,Class #02
AUDE-92552-PURE TONE AUDIOMETRY -AIR ONLY 1 1.000000 11.8600 11.8600
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 5 5.000000 41.4000 8.2800
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 2 2.000000 20.7600 10.3800
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 5 5.000000 105.4000 21.0800
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 1 1.000000 27.1900 27.1900
EVAL-EVAL-DEVELOPMENTAL EVALUATION 1 1.500000 75.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 15 25.500000 1912.5000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 4 6.500000 487.5000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 5 8.000000 600.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 8 13.000000 975.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 15 24.500000 1359.7500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 166 263.293134 19641.8400 74.6007
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 67 105.003100 7838.3100 74.6484
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 60 99.500000 7352.4500 73.8940
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 149 243.000000 13425.5000 55.2490
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 60 95.166600 7137.5000 75.0001
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 7 7.000000 1295.0000 185.0000
SCREEN-T1023-INTERDISCIPLINARY SCREENING 1 1.000000 50.0000 50.0000
SPCH-92506-SPEECH EVAL BY LICENSED SLP 1 1.000000 48.5000 48.5000
Subtotal (Total Children Is Unduplicated) 321 907.962834 62405.4600 68.7313
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EI Services,Class #03
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 1 2.000000 135.7600 67.8800
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 1 30.000000 15.0000 0.5000
Subtotal (Total Children Is Unduplicated) 2 32.000000 150.7600 4.7113
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Total 959.212834 63268.4700 65.9587
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Number of Children (Unduplicated) With at Least One Service 326
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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 15 21.500000 1261.5000 0.0000
S 0 0.000000 0.0000 0.0000
H 5 6.000000 425.0000 0.0000
T 0 0.000000 0.0000 0.0000
3 3.500000 262.5000 0.0000
Other 16 19.000000 1425.0000 0.0000
---------------------------------------------------------
Total 39 50.000000 3374.0000 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
2 4.500000 242.5000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 2 4.500000 242.5000 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
44 69.000000 5136.0000 0.0000
Other 6 6.000000 88.0800 0.0000
---------------------------------------------------------
Total 50 75.000000 5224.0800 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 9 7.500000 944.0000 1345.7400
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
28 27.000000 1887.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 37 34.500000 2831.0000 1345.7400
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
32 39.000000 2625.4900 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 32 39.000000 2625.4900 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
3 6.500000 487.5000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 3 6.500000 487.5000 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
180 305.500000 21528.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 180 305.500000 21528.0000 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 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
138 232.500000 15313.5500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 138 232.500000 15313.5500 0.0000
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
3 3.500000 262.5000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 3 3.500000 262.5000 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 7 12.500000 585.3800 585.3800
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 5 10.000000 633.0000 0.0000
T 0 0.000000 0.0000 0.0000
11 19.500000 1287.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 23 42.000000 2505.3800 585.3800
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 52.000000 3317.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 26 52.000000 3317.0000 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 2 2.203500 165.2700 165.2700
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
13 48.000000 1326.0000 0.0000
Other 7 13.000000 838.5000 0.0000
---------------------------------------------------------
Total 22 63.203500 2329.7700 165.2700
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
33 51.009334 3227.7000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 33 51.009334 3227.7000 0.0000