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
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 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-92555-SPEECH AUD THRESHOLD (DETECTION) 15 16.000000 145.7600 9.1100
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 6 6.000000 56.0400 9.3400
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 17 18.000000 391.1400 21.7300
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 26 49.500000 3712.5000 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 4 7.000000 525.0000 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 142 260.000000 19500.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 83 152.000000 11400.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 42 76.000000 5700.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 195 350.500000 19452.7500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 95 137.000000 10275.0000 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
PSTH-97001-EVAL BY LICENSED PT, INITIAL 1 1.000000 48.5000 48.5000
Subtotal (Total Children Is Unduplicated) 380 1194.500000 84300.9400 70.5742
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 39 108.036800 5401.8400 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 4 12.000000 814.5600 67.8800
PHY-97110-PT SESSION BY LICENSED PT 1 1.000000 67.8800 67.8800
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 36 178.000000 12082.6400 67.8800
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 2 82.000000 41.0000 0.5000
Subtotal (Total Children Is Unduplicated) 80 381.036800 18407.9200 48.3101
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Total 1613.036800 104059.3600 64.5115
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Number of Children (Unduplicated) With at Least One Service 467
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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 0 0.000000 0.0000 0.0000
12 12.000000 444.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 12 12.000000 444.0000 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
51 78.500000 5768.4400 0.0000
Other 40 40.000000 592.9400 0.0000
---------------------------------------------------------
Total 91 118.500000 6361.3800 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 302.5600
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
80 73.500000 9552.5000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 81 74.500000 9832.5000 302.5600
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 18 22.000000 1389.4000 1389.4000
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
440 686.500000 46550.7400 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 458 708.500000 47940.1400 1389.4000
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
257 457.000000 31281.7500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 257 457.000000 31281.7500 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 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
62 149.500000 3467.0000 0.0000
Other 13 13.000000 650.0000 0.0000
---------------------------------------------------------
Total 82 167.764000 4380.2000 403.5500
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
19 20.750000 1094.2500 0.0000
Other 12 12.250000 662.5000 0.0000
---------------------------------------------------------
Total 45 42.272800 2220.3900 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
17 21.000000 834.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 18 22.500000 946.5000 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 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
6 10.000000 652.5000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 6 10.000000 652.5000 0.0000