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: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 2 0.750000 27.7500 37.0000
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 1 1.000000 0.0000 0.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 2 2.000000 74.0000 37.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 17 33.750000 1248.7500 37.0000
Subtotal (Total Children Is Unduplicated) 18 37.500000 1350.5000 36.0133
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Screening, Eval, and Assessment,Class #02
AUDE-92552-PURE TONE AUDIOMETRY -AIR ONLY 1 1.000000 13.0500 13.0500
AUDE-92553-PURE TONE AUDIOMETRY AIR & BONE 1 1.000000 0.9900 0.9900
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 16 17.000000 154.8700 9.1100
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 7 7.000000 65.3800 9.3400
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 20 21.000000 438.7600 20.8933
AUDE-V5090-DISPENSING FEE PER HEARING AID 1 2.000000 230.0000 115.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 29 54.500000 4087.5000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 10 19.500000 1462.5000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 6 11.000000 825.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 18 32.500000 2437.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 25 43.500000 2414.2500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 175 318.500000 23887.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 87 158.268000 11870.1000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 68 122.500000 9187.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 196 352.000000 19536.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 97 141.000000 10575.0000 75.0000
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 21 21.000000 5880.0000 280.0000
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 5 5.000000 900.0000 180.0000
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 16 15.813000 766.4300 48.4683
PSTH-97001-EVAL BY LICENSED PT, INITIAL 8 8.000000 388.0000 48.5000
SPCH-92506-SPEECH EVAL BY LICENSED SLP 24 23.891800 1125.2500 47.0977
Subtotal (Total Children Is Unduplicated) 445 1375.972800 96245.5800 69.9473
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 12 70.000000 5158.1500 73.6879
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 1 20.000000 1000.0000 50.0000
EIIF-EIIF_NM-EI INDIVIDUAL SESSION BY NONMED PROF 1 1.000000 50.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 71 317.947800 15897.3900 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 112 441.815414 29643.1300 67.0939
OCCT-97530HM-OT SESSION BY OT ASST 5 31.000000 1599.4000 51.5935
PHY-97110-PT SESSION BY LICENSED PT 199 823.615984 55138.0200 66.9463
PHY-97110HM-PT SESSION BY PT ASST 8 20.704900 1124.6900 54.3200
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 257 1070.557819 72413.5343 67.6409
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 2 3.000000 162.9600 54.3200
SPL-92508-GROUP SPL SESSION PER CHILD 1 3.000000 39.6000 13.2000
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 2 82.000000 41.0000 0.5000
Subtotal (Total Children Is Unduplicated) 543 2884.641917 182267.8743 63.1856
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Total 4298.114717 279863.9543 65.1132
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Number of Children (Unduplicated) With at Least One Service 924
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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 1 1.000000 50.0000 50.0000
18 22.500000 1206.5000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 19 23.500000 1256.5000 50.0000
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
86 142.500000 8733.3900 0.0000
Other 40 40.000000 592.9400 0.0000
---------------------------------------------------------
Total 126 182.500000 9326.3300 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 39 131.000000 7083.9600 3385.5000
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 3 3.000000 185.7600 185.7600
T 0 0.000000 0.0000 0.0000
80 73.500000 9552.5000 0.0000
Other 34 59.500000 3865.1600 1629.9400
---------------------------------------------------------
Total 156 267.000000 20687.3800 5201.2000
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 63 149.000000 9187.6800 9187.6800
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
763 1300.250000 88758.9900 131.2000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 826 1449.250000 97946.6700 9318.8800
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
637 1159.250000 77986.7000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 637 1159.250000 77986.7000 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 7 5.264000 263.2000 403.5500
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 1 1.000000 50.0000 50.0000
T 0 0.000000 0.0000 0.0000
85 171.422200 4856.4143 0.0000
Other 13 13.000000 650.0000 0.0000
---------------------------------------------------------
Total 106 190.686200 5819.6143 453.5500
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 14 9.272800 463.6400 705.6000
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
138 150.999000 9412.0200 0.0000
Other 12 12.250000 662.5000 0.0000
---------------------------------------------------------
Total 164 172.521800 10538.1600 705.6000
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 1 1.500000 112.5000 0.0000
T 0 0.000000 0.0000 0.0000
588 481.034417 31602.9800 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 589 482.534417 31715.4800 0.0000
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 2 1.122300 54.4300 54.4300
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 7 11.000000 545.5000 545.5000
183 358.750000 23987.1900 23396.9100
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 192 370.872300 24587.1200 23996.8400