CMS/EIP Fiscal Report Statewide
Services beginning 07/01/2012 ending 09/30/2012 Date of Report:11/15/2012 Page: 1
List order: No List
Payclass Filters:GR
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 425 372.250000 13764.0000 36.9752
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 181 185.000000 0.0000 0.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 603 643.000000 23791.0000 37.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 503 1894.500000 70078.0000 36.9902
Subtotal (Total Children Is Unduplicated) 1097 3094.750000 107633.0000 34.7792
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Screening, Eval, and Assessment,Class #02
AUDE-92552-PURE TONE AUDIOMETRY -AIR ONLY 8 8.000000 96.3300 12.0413
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 7 7.000000 62.1100 8.8729
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 7 7.000000 67.4600 9.6371
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 8 8.000000 161.4800 20.1850
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 4 4.000000 100.6000 25.1500
EVAL-EVAL-DEVELOPMENTAL EVALUATION 5 11.000000 550.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 8 12.500000 937.5000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 3 5.500000 412.5000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 1.500000 112.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 3 4.000000 300.0000 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 110 156.880100 11579.9500 73.8140
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 33 51.000000 3825.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 24 28.500000 2137.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 133 217.500000 12071.2500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 96 102.175067 7663.1300 75.0000
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 2 2.000000 81.0000 40.5000
SCREEN-T1023-INTERDISCIPLINARY SCREENING 3 3.000000 150.0000 50.0000
SPCH-92506-SPEECH EVAL BY LICENSED SLP 2 2.000000 97.0000 48.5000
Subtotal (Total Children Is Unduplicated) 298 656.055167 41765.0600 63.6609
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EI Services,Class #03
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 1 0.500000 25.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 1 1.000000 50.0000 50.0000
INTR-INTR-INTERPRETER 18 17.250000 747.5000 43.3333
TRAN-TRAN-FAMILY TRANSPORTATION 76 78.000000 624.0000 8.0000
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 248 16228.00000 8163.0000 0.5030
Subtotal (Total Children Is Unduplicated) 339 16324.75000 9609.5000 0.5886
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Total 20075.555167 159007.5600 7.9205
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Number of Children (Unduplicated) With at Least One Service 1124
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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 26 548.750000 867.8600 867.8600
D 0 0.000000 0.0000 0.0000
S 1 0.500000 18.5000 0.0000
H 0 0.000000 0.0000 0.0000
T 13 359.500000 723.0000 723.0000
212 182.750000 7375.8300 0.0000
Other 12 160.500000 794.2500 0.0000
---------------------------------------------------------
Total 264 1252.000000 9779.4400 1590.8600
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 31 873.000000 1560.2500 1560.2500
129 694.250000 3651.5000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 160 1567.250000 5211.7500 1560.2500
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 1 26.000000 13.0000 13.0000
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
832 2020.750000 28212.7500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 833 2046.750000 28225.7500 13.0000
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 0 0.000000 0.0000 0.0000
D 5 9.000000 333.0000 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
458 612.750000 18477.7500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 463 621.750000 18810.7500 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 39 1040.000000 1719.0000 1719.0000
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
387 1032.500000 13617.7500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 426 2072.500000 15336.7500 1719.0000
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 368 1282.750000 14802.5000 14802.5000
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
0 0.000000 0.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 368 1282.750000 14802.5000 14802.5000
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 35 37.000000 637.9800 637.9800
D 4 3.000000 111.0000 111.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
656 662.500000 25719.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 695 702.500000 26467.9800 748.9800
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 3 60.000000 30.0000 30.0000
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
17 45.250000 562.7500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 20 105.250000 592.7500 30.0000
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 14 467.000000 382.5000 382.5000
T 146 2441.000000 3923.0000 3923.0000
185 1910.250000 4903.2500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 345 4818.250000 9208.7500 4305.5000
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 0 0.000000 0.0000 0.0000
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 37 996.500000 1108.5000 1108.5000
T 166 1875.500000 4846.7500 4846.7500
362 2170.500000 10591.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 565 5042.500000 16546.2500 5955.2500
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 10 23.380100 938.5100 938.5100
D 6 6.000000 279.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 5 8.500000 637.5000 637.5000
158 124.675067 3514.6300 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 179 162.555167 5369.6400 1576.0100
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 3 222.000000 254.0000 254.0000
144 179.500000 8401.2500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 147 401.500000 8655.2500 254.0000