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
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 4 4.750000 175.7500 37.0000
Subtotal (Total Children Is Unduplicated) 4 4.750000 175.7500 37.0000
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Screening, Eval, and Assessment,Class #02
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 25 26.000000 248.6900 9.5650
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 11 11.000000 97.1600 8.8327
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 25 26.000000 555.4900 21.3650
AUDE-92585-AUD EVOKED RESPONSE (DIAG) 1 1.000000 56.9400 56.9400
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 2 2.000000 46.4900 23.2450
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 23 41.500000 3112.5000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 3 3.000000 225.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 5 8.500000 637.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 25 37.500000 2812.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 9 15.500000 860.2500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 130 222.000000 16650.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 84 130.000000 9750.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 70 113.500000 8512.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 128 217.000000 12043.5000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 178 259.500000 19425.0000 74.8555
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 27 27.000000 7560.0000 280.0000
MED-99204-OUTPATIENT VISIT, NEW, 45 MINS 1 1.000000 420.0000 420.0000
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 8 8.000000 1440.0000 180.0000
PSTH-97001-EVAL BY LICENSED PT, INITIAL 1 1.000000 48.5000 48.5000
Subtotal (Total Children Is Unduplicated) 426 1151.000000 84502.0200 73.4162
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EI Services,Class #03
PHY-97110-PT SESSION BY LICENSED PT 13 50.250000 3410.9700 67.8800
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 28 176.000000 11946.8800 67.8800
Subtotal (Total Children Is Unduplicated) 41 226.250000 15357.8500 67.8800
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Total 1382.000000 100035.6200 72.3847
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Number of Children (Unduplicated) With at Least One Service 463
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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
121 168.250000 12277.1900 0.0000
Other 66 66.000000 1004.7700 0.0000
---------------------------------------------------------
Total 187 234.250000 13281.9600 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 26 26.000000 3122.0000 4637.8200
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
72 63.500000 9891.2500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 98 89.500000 13013.2500 4637.8200
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
426 589.000000 41085.1600 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 426 589.000000 41085.1600 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
255 431.500000 30042.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 255 431.500000 30042.0000 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 1 1.500000 112.5000 58.4100
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 17 25.500000 1912.5000 0.0000
T 0 0.000000 0.0000 0.0000
5 6.250000 421.7500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 23 33.250000 2446.7500 58.4100
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 0 0.000000 0.0000 0.0000
9 4.500000 166.5000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 9 4.500000 166.5000 0.0000