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
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
TCM-T1017TL-TARGETED CASE MANAGEMENT 11 10.750000 388.5000 36.1395
Subtotal (Total Children Is Unduplicated) 11 10.750000 388.5000 36.1395
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Screening, Eval, and Assessment,Class #02
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 18 18.000000 163.9800 9.1100
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 8 8.000000 74.7200 9.3400
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 17 17.000000 369.4100 21.7300
BEHV-BEHV-BEHAVIORAL ASSESSMENT 1 1.000000 125.0000 125.0000
EVAL-EVAL-DEVELOPMENTAL EVALUATION 2 2.000000 100.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 18 35.000000 2625.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 7 12.500000 937.5000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 3 5.500000 412.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 18 31.500000 2362.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 14 25.000000 1387.5000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 141 257.500000 19312.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 68 124.500000 9337.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 55 95.000000 7125.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 200 351.000000 19480.5000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 141 198.823333 14911.7500 75.0000
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 31 31.000000 8680.0000 280.0000
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 1 1.000000 180.0000 180.0000
PSTH-97001-EVAL BY LICENSED PT, INITIAL 3 3.000000 145.5000 48.5000
Subtotal (Total Children Is Unduplicated) 405 1217.323333 87730.8600 72.0687
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 1 4.000000 200.0000 50.0000
PHY-97110-PT SESSION BY LICENSED PT 11 24.750000 1680.0300 67.8800
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 44 246.000000 16698.4800 67.8800
Subtotal (Total Children Is Unduplicated) 56 274.750000 18578.5100 67.6197
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Total 1502.823333 106697.8700 70.9983
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Number of Children (Unduplicated) With at Least One Service 465
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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
14 10.750000 388.5000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 14 10.750000 388.5000 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
52 69.750000 4989.7700 0.0000
Other 43 43.000000 608.1100 0.0000
---------------------------------------------------------
Total 95 112.750000 5597.8800 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 17 14.000000 2316.7500 4215.2200
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
87 81.500000 10662.2500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 104 95.500000 12979.0000 4215.2200
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 11 11.000000 675.1600 675.1600
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
482 699.500000 47748.0700 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 493 710.500000 48423.2300 675.1600
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
316 554.500000 37911.7500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 316 554.500000 37911.7500 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 3 3.323333 249.2500 390.8400
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 8 11.000000 850.0000 0.0000
T 0 0.000000 0.0000 0.0000
4 4.500000 298.2600 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 15 18.823333 1397.5100 390.8400