CMS/EIP Fiscal Report Statewide
Services beginning 04/01/2013 ending 06/30/2013 Date of Report:08/19/2013 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 1 0.750000 27.7500 37.0000
Subtotal (Total Children Is Unduplicated) 1 0.750000 27.7500 37.0000
-----------------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
ASTE-ASTE-ASSISTIVE TECHNOLOGY EVAL 1 1.000000 48.5000 48.5000
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 28 29.000000 264.1900 9.1100
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 10 10.000000 93.4000 9.3400
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 27 28.000000 608.4400 21.7300
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 27 52.000000 3900.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 10 17.500000 1312.5000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 2.000000 150.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 20 39.500000 2962.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 21 37.500000 2081.2500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 120 212.500000 15937.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 59 106.500000 7987.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 79 132.000000 9900.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 174 323.500000 17954.2500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 147 208.112667 15608.4500 75.0000
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 35 35.000000 9800.0000 280.0000
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 2 2.000000 360.0000 180.0000
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 1 1.000000 48.5000 48.5000
PSTH-97001-EVAL BY LICENSED PT, INITIAL 4 4.000000 194.0000 48.5000
Subtotal (Total Children Is Unduplicated) 408 1241.112667 89210.9800 71.8798
-----------------------------------------------------------------------------------------------------------------------
EI Services,Class #03
OCCT-97530-OT SESSION BY LICENSED OT 1 3.000000 203.6400 67.8800
PHY-97110-PT SESSION BY LICENSED PT 8 30.500000 2070.3400 67.8800
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 49 255.000000 17309.4000 67.8800
Subtotal (Total Children Is Unduplicated) 57 288.500000 19583.3800 67.8800
-----------------------------------------------------------------------------------------------------------------------
Total 1530.362667 108822.1100 71.1087
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 455
-----------------------------------------------------------------------------------------------------------------------
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
1 0.750000 27.7500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 1 0.750000 27.7500 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
68 91.500000 6479.2200 0.0000
Other 67 67.000000 966.0300 0.0000
---------------------------------------------------------
Total 135 158.500000 7445.2500 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 7 7.000000 1081.5000 1904.0600
D 1 1.000000 280.0000 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
85 76.500000 12078.2500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 93 84.500000 13439.7500 1904.0600
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 10 11.000000 729.0400 729.0400
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
519 749.500000 50919.8700 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 529 760.500000 51648.9100 729.0400
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
289 510.000000 35052.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 289 510.000000 35052.0000 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 2 2.612667 195.9500 228.4500
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 5 7.500000 562.5000 0.0000
T 0 0.000000 0.0000 0.0000
4 6.000000 450.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 11 16.112667 1208.4500 228.4500