CMS/EIP Fiscal Report Statewide
Services beginning 07/01/2012 ending 09/30/2012 Date of Report:11/16/2012 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 6 6.250000 231.2500 37.0000
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 1 1.000000 0.0000 0.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 4 4.000000 148.0000 37.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 39 104.000000 3857.2500 37.0889
TCON-TCON-TRANSITION CONFERENCE 1 1.000000 0.0000 0.0000
Subtotal (Total Children Is Unduplicated) 42 116.250000 4236.5000 36.4430
-----------------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 30 30.000000 264.1700 8.8057
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 10 10.000000 96.5200 9.6520
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 28 28.000000 601.2900 21.4746
AUDE-92585-AUD EVOKED RESPONSE (DIAG) 1 1.000000 56.9400 56.9400
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 1 1.000000 27.1900 27.1900
EVAL-EVAL-DEVELOPMENTAL EVALUATION 2 3.500000 175.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 34 63.500000 4762.5000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 8 14.500000 1087.5000 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 24 46.000000 3450.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 21 36.000000 1998.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 151 274.897200 20617.2900 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 102 177.000000 13275.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 45 78.000000 5850.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 236 406.500000 22560.7500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 129 201.231868 15092.3900 75.0000
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 16 16.000000 4480.0000 280.0000
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 2 2.000000 360.0000 180.0000
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 1 1.000000 48.5000 48.5000
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 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) 493 1399.129068 95350.0400 68.1496
-----------------------------------------------------------------------------------------------------------------------
EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 2 2.000000 100.0000 50.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 1 1.000000 50.0000 50.0000
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 1 1.000000 25.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 81 434.160000 21708.0000 50.0000
HERN-T1027SC-EI HEARING SERVICES AFTER SHINE 3 6.000000 300.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 5 25.750000 1747.9100 67.8800
PHY-97110-PT SESSION BY LICENSED PT 3 11.000000 746.6800 67.8800
SHIN-T1027SC-INITIAL SHINE SERVICES, INDIVIDUAL 3 5.000000 250.0000 50.0000
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 24 96.250000 6533.4500 67.8800
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 3 280.000000 140.0000 0.5000
Subtotal (Total Children Is Unduplicated) 115 862.160000 31601.0400 36.6533
-----------------------------------------------------------------------------------------------------------------------
Total 2377.539068 131187.5800 55.1779
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 615
-----------------------------------------------------------------------------------------------------------------------
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 32 42.500000 2322.5000 0.0000
S 0 0.000000 0.0000 0.0000
H 18 22.500000 1500.0000 0.0000
T 0 0.000000 0.0000 0.0000
3 3.000000 150.0000 0.0000
Other 1 2.000000 150.0000 0.0000
---------------------------------------------------------
Total 54 70.000000 4122.5000 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
5 4.500000 166.5000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 5 4.500000 166.5000 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
75 121.250000 8892.1500 0.0000
Other 70 70.000000 1046.1100 0.0000
---------------------------------------------------------
Total 145 191.250000 9938.2600 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 1 1.000000 280.0000 252.4000
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
69 65.000000 7341.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 70 66.000000 7621.0000 252.4000
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 32.000000 165.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 2 32.000000 165.0000 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 12 12.000000 600.0000 600.0000
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
333 545.250000 37629.5100 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 345 557.250000 38229.5100 600.0000
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
274 488.000000 33041.2500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 274 488.000000 33041.2500 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 0.660000 33.0000 33.0000
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 1 1.000000 50.0000 50.0000
295 304.250000 15896.0000 0.0000
Other 30 30.500000 1533.2500 0.0000
---------------------------------------------------------
Total 331 336.410000 17512.2500 83.0000
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 6 5.556400 322.9800 438.9900
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
232 473.500000 12098.6300 0.0000
Other 58 64.500000 3441.0000 0.0000
---------------------------------------------------------
Total 296 543.556400 15862.6100 438.9900
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 9 9.322668 699.2000 905.8600
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 4 6.000000 450.0000 0.0000
T 0 0.000000 0.0000 0.0000
40 53.250000 2084.2500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 53 68.572668 3233.4500 905.8600
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
14 20.000000 1295.2500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 14 20.000000 1295.2500 0.0000