CMS/EIP Fiscal Report Statewide
Services beginning 10/01/2013 ending 12/31/2013 Date of Report:02/18/2014 Page: 1
List order: No List
Eligibility Filter:Not Part C
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
CASE-CASE-NON-TCM CASE MANAGEMENT 254 276.000000 10212.0000 37.0000
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 133 133.000000 0.0000 0.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 242 188.500000 6974.5000 37.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 662 2661.750000 98484.7500 37.0000
Subtotal (Total Children Is Unduplicated) 674 3259.250000 115671.2500 35.4901
-----------------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
AUDE-92552-PURE TONE AUDIOMETRY -AIR ONLY 4 4.000000 57.4400 14.3600
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 4 4.000000 40.0800 10.0200
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 4 4.000000 33.6400 8.4100
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 4 4.000000 84.0000 21.0000
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 3 3.000000 66.0600 22.0200
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 15 19.000000 1425.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 6 9.000000 675.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 4 3.500000 262.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 5 6.000000 450.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 20 29.000000 1609.5000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 256 379.000000 28425.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 105 151.000000 11325.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 110 145.000000 10875.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 371 534.500000 29664.7500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 224 270.500000 20287.5000 75.0000
MED-99202-OUTPATIENT VISIT, NEW, 20 MINS 14 14.000000 869.4200 62.1014
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 44 44.000000 4676.2600 106.2786
SCREEN-T1023-SCREENING 1 3.000000 150.0000 50.0000
Subtotal (Total Children Is Unduplicated) 554 1626.500000 110976.1500 68.2300
-----------------------------------------------------------------------------------------------------------------------
EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 1 4.000000 200.0000 50.0000
INTR-INTR-INTERPRETER 48 92.750000 4637.5000 50.0000
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 1 0.500000 33.9400 67.8800
TRAN-TRAN-FAMILY TRANSPORTATION 95 100.000000 800.0000 8.0000
TRAV-FLAT-PROV TRAVEL TO NATL ENV $10 PER CHILD 1 4.000000 40.0000 10.0000
TRAV-TRAV-PROV TRAVEL TO NATURAL ENV PER MINUTE 12 968.000000 521.6000 0.5388
Subtotal (Total Children Is Unduplicated) 155 1169.250000 6233.0400 5.3308
-----------------------------------------------------------------------------------------------------------------------
Total 6055.000000 232880.4400 38.4608
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 681
-----------------------------------------------------------------------------------------------------------------------
Center 02
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 7 3.750000 138.7500 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 5.500000 203.5000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 18 9.250000 342.2500 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
31 13.500000 462.5000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 31 13.500000 462.5000 0.0000
Center 04
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 11 7.000000 525.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 138 246.250000 10008.0000 0.0000
P 175 242.500000 11114.0100 11619.6000
D 1 0.750000 27.7500 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
781 879.750000 30866.4200 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 1106 1376.250000 52541.1800 11619.6000
Center 09
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 477 773.750000 40692.2500 0.0000
P 547 1333.000000 22861.2500 22861.2500
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
151 245.250000 16769.5000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 1175 2352.000000 80323.0000 22861.2500
Center 10
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 6 6.250000 231.2500 0.0000
U 0 0.000000 0.0000 0.0000
B 705 717.250000 30134.0000 0.0000
P 133 188.000000 11583.9100 11583.9100
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
717 837.000000 40214.2500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 1561 1748.500000 82163.4100 11583.9100
Center 57
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 2 1.500000 55.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 55 59.500000 2927.2500 0.0000
P 77 99.500000 4585.0000 4585.0000
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 5 192.000000 171.6000 171.6000
190 203.000000 9308.7500 200.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 329 555.500000 17048.1000 4956.6000