CMS/EIP Fiscal Report Statewide
Services beginning 01/01/2013 ending 03/31/2013 Date of Report:05/17/2013 Page: 1
List order: No List
Payclass Filters:TPIN
Eligibility Filter:Not Part C
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Screening, Eval, and Assessment,Class #02
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 5 6.000000 54.6600 9.1100
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 1 2.000000 18.6800 9.3400
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 5 6.000000 130.3800 21.7300
EVAL-EVAL-DEVELOPMENTAL EVALUATION 1 4.000000 200.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 7 11.000000 825.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 1.000000 75.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 1 2.000000 150.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 8 13.500000 749.2500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 83 135.601700 10170.1300 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 31 46.768000 3507.6000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 29 47.500000 3562.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 94 152.000000 8436.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 25 29.000000 2175.0000 75.0000
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 8 8.000000 2240.0000 280.0000
Subtotal (Total Children Is Unduplicated) 164 464.369700 32294.2000 69.5442
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Total 464.369700 32294.2000 69.5442
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Number of Children (Unduplicated) With at Least One Service 164
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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
17 26.000000 1950.0000 0.0000
Other 14 14.000000 203.7200 0.0000
---------------------------------------------------------
Total 31 40.000000 2153.7200 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 5 3.500000 438.2500 1108.4600
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
30 26.000000 3112.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 35 29.500000 3550.2500 1108.4600
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 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
108 181.500000 12471.7500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 108 181.500000 12471.7500 0.0000
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
118 195.000000 12840.7500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 118 195.000000 12840.7500 0.0000
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 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
11 18.369700 1277.7300 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 11 18.369700 1277.7300 0.0000