CMS/EIP Fiscal Report Statewide
Services beginning 04/01/2012 ending 06/30/2012 Date of Report:08/16/2012 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
TCM-T1017TL-TARGETED CASE MANAGEMENT 22 63.250000 2321.7500 36.7075
Subtotal (Total Children Is Unduplicated) 22 63.250000 2321.7500 36.7075
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Screening, Eval, and Assessment,Class #02
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 16 16.000000 132.4800 8.2800
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 12 12.000000 124.5600 10.3800
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 16 16.000000 337.2800 21.0800
AUDE-92585-AUD EVOKED RESPONSE (DIAG) 1 1.000000 51.7600 51.7600
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 1 1.000000 27.1900 27.1900
BEHV-H0031HO-COMP BEHAVIORAL HEALTH ASSESSMENT 1 2.000000 250.0000 125.0000
EVAL-EVAL-DEVELOPMENTAL EVALUATION 11 19.000000 950.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 30 57.000000 4275.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 2.000000 150.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 2 4.000000 300.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 25 46.539467 3490.4600 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 22 37.000000 2053.5000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 176 307.000000 23025.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 91 158.000000 11850.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 53 89.500000 6712.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 286 481.000000 26695.5000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 118 184.000000 13800.0000 75.0000
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 31 31.000000 5590.5000 180.3387
MED-99204-OUTPATIENT VISIT, NEW, 45 MINS 3 3.000000 171.8100 57.2700
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 2 2.000000 210.0000 105.0000
PSTH-97001-EVAL BY LICENSED PT, INITIAL 1 1.000000 48.5000 48.5000
SCREEN-T1023-INTERDISCIPLINARY SCREENING 6 6.000000 300.0000 50.0000
Subtotal (Total Children Is Unduplicated) 529 1476.039467 100546.0400 68.1188
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 3 4.000000 200.0000 50.0000
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 1 2.000000 100.0000 50.0000
CONIP-CONIP-CONSULT, ITDS, PHONE 1 1.000000 25.0000 25.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 2 3.000000 150.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 77 276.750000 13875.0000 50.1355
HERN-T1027SC-EI HEARING SERVICES AFTER SHINE 1 4.000000 200.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 2 2.000000 135.7600 67.8800
OCCT-97530HM-OT SESSION BY OT ASST 1 1.000000 54.3200 54.3200
PHY-97110-PT SESSION BY LICENSED PT 8 40.000000 2715.2000 67.8800
SHIN-T1027SC-INITIAL SHINE SERVICES, INDIVIDUAL 2 4.000000 200.0000 50.0000
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 14 67.000000 4547.9600 67.8800
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 2 155.000000 77.5000 0.5000
Subtotal (Total Children Is Unduplicated) 106 559.750000 22280.7400 39.8048
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Total 2099.039467 125148.5300 59.6218
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Number of Children (Unduplicated) With at Least One Service 635
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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 5 9.000000 450.0000 761.9100
D 71 105.500000 5819.7500 0.0000
S 1 1.000000 55.5000 0.0000
H 32 43.000000 2950.0000 0.0000
T 0 0.000000 0.0000 0.0000
0 0.000000 0.0000 0.0000
Other 1 1.500000 112.5000 0.0000
---------------------------------------------------------
Total 110 160.000000 9387.7500 761.9100
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
9 9.250000 379.2500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 9 9.250000 379.2500 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
65 120.000000 6956.1000 0.0000
Other 16 16.000000 275.8700 0.0000
---------------------------------------------------------
Total 81 136.000000 7231.9700 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 4 4.000000 371.0000 670.7900
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
90 89.000000 8876.5000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 94 93.000000 9247.5000 670.7900
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
98 128.500000 7283.7100 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 98 128.500000 7283.7100 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
4 3.500000 129.5000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 4 3.500000 129.5000 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 16 18.000000 1104.0400 1104.0400
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
322 535.500000 36761.0700 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 338 553.500000 37865.1100 1104.0400
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
252 437.000000 29830.5000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 252 437.000000 29830.5000 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 11 20.750000 1147.6700 0.0000
T 0 0.000000 0.0000 0.0000
10 13.250000 715.9100 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 21 34.000000 1863.5800 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 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
185 222.750000 11666.2000 0.0000
Other 1 0.500000 25.0000 0.0000
---------------------------------------------------------
Total 186 223.250000 11691.2000 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 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
88 224.500000 5068.0000 0.0000
Other 50 57.000000 3056.5000 0.0000
---------------------------------------------------------
Total 138 281.500000 8124.5000 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 2 2.039467 152.9600 220.4600
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 3 5.000000 475.0000 0.0000
T 0 0.000000 0.0000 0.0000
19 26.500000 1094.5000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 24 33.539467 1722.4600 220.4600
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
4 6.000000 391.5000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 4 6.000000 391.5000 0.0000