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
Payclass Filters:GR
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 292 1128.250000 41745.2500 37.0000
Subtotal (Total Children Is Unduplicated) 549 1725.750000 58931.7500 34.1485
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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 3 3.500000 262.5000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 2 1.000000 75.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 1 2.000000 111.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 46 60.500000 4537.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 7 10.500000 787.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 16 18.500000 1387.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 60 76.500000 4245.7500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 25 28.000000 2100.0000 75.0000
MED-99202-OUTPATIENT VISIT, NEW, 20 MINS 11 11.000000 299.4200 27.2200
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 30 30.000000 1215.0000 40.5000
SCREEN-T1023-SCREENING 1 3.000000 150.0000 50.0000
Subtotal (Total Children Is Unduplicated) 140 263.500000 15452.3900 58.6428
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EI Services,Class #03
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 1165.250000 6033.0400 5.1775
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Total 3154.500000 80417.1800 25.4928
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Number of Children (Unduplicated) With at Least One Service 576
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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
11 5.500000 203.5000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 11 5.500000 203.5000 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
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 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 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
669 779.000000 22459.6700 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 670 779.750000 22487.4200 0.0000
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 541 1322.750000 22207.2500 22207.2500
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
5 5.500000 229.5000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 546 1328.250000 22436.7500 22207.2500
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 23 25.500000 615.1600 615.1600
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
574 611.000000 24931.5000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 597 636.500000 25546.6600 615.1600
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 5 192.000000 171.6000 171.6000
188 199.000000 9108.7500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 193 391.000000 9280.3500 171.6000