CMS/EIP Fiscal Report Statewide
Services beginning 10/01/2012 ending 12/31/2012 Date of Report:02/16/2013 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 423 667.500000 24660.5000 36.9446
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 179 184.000000 0.0000 0.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 453 389.000000 14365.2500 36.9287
TCM-T1017TL-TARGETED CASE MANAGEMENT 340 1273.250000 47073.2500 36.9709
Subtotal (Total Children Is Unduplicated) 907 2513.750000 86099.0000 34.2512
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Screening, Eval, and Assessment,Class #02
AUDE-92552-PURE TONE AUDIOMETRY -AIR ONLY 2 2.000000 26.1000 13.0500
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 2 2.000000 18.2200 9.1100
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 2 2.000000 18.6800 9.3400
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 2 2.000000 43.4600 21.7300
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 1 1.000000 24.4700 24.4700
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 6 10.000000 750.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 2 3.500000 262.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 2 2.000000 150.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 8 14.000000 777.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 106 154.063200 11554.7400 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 60 98.297333 7372.3000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 31 32.500000 2437.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 159 247.000000 13708.5000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 67 60.688700 4551.6500 75.0000
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 3 3.000000 121.5000 40.5000
SPCH-92506-SPEECH EVAL BY LICENSED SLP 5 5.000000 242.5000 48.5000
Subtotal (Total Children Is Unduplicated) 284 639.049233 42059.1200 65.8151
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EI Services,Class #03
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 1 1.000000 50.0000 50.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 1 1.000000 50.0000 50.0000
CONSP-CONSP-CONSULT, SLP, PHONE 1 0.500000 12.5000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 1 3.000000 150.0000 50.0000
INTR-INTR-INTERPRETER 26 40.000000 1970.0000 49.2500
TRAN-TRAN-FAMILY TRANSPORTATION 92 96.000000 768.0000 8.0000
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 117 10661.00000 5368.3000 0.5035
Subtotal (Total Children Is Unduplicated) 231 10802.50000 8368.8000 0.7747
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Total 13955.299233 136526.9200 9.7832
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Number of Children (Unduplicated) With at Least One Service 925
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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 58 2129.500000 2773.5000 2773.5000
280 1435.000000 6727.2500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 338 3564.500000 9500.7500 2773.5000
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 4 7.000000 525.0000 525.0000
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
1276 1929.000000 42251.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 1280 1936.000000 42776.0000 525.0000
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 2 3.000000 111.0000 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
529 651.750000 18918.5000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 531 654.750000 19029.5000 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 431 1750.500000 17825.7500 17825.7500
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
7 7.750000 286.7500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 438 1758.250000 18112.5000 17825.7500
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 9 9.000000 130.9300 130.9300
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
570 545.500000 21531.2500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 579 554.500000 21662.1800 130.9300
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 125 2055.500000 3564.0000 3564.0000
T 0 0.000000 0.0000 0.0000
0 0.000000 0.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 125 2055.500000 3564.0000 3564.0000
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 154 2845.188700 4772.4000 4772.4000
T 0 0.000000 0.0000 0.0000
0 0.000000 0.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 154 2845.188700 4772.4000 4772.4000
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 18 28.863600 2086.7700 2086.7700
D 14 16.250000 772.2500 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 12 18.996933 1424.7700 1424.7700
184 138.000000 3368.5000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 228 202.110533 7652.2900 3511.5400
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 2 2.000000 150.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 3 189.000000 132.3000 132.3000
154 193.500000 9175.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 159 384.500000 9457.3000 132.3000