CMS/EIP Fiscal Report Statewide
Services beginning 01/01/2014 ending 03/31/2014 Date of Report:06/03/2014 Page: 1
List order: No List
Payclass Filters:TPIN
Eligibility Filter:Not Part C
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Screening, Eval, and Assessment,Class #02
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 2 2.000000 20.0400 10.0200
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 1 1.000000 8.4100 8.4100
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 2 2.000000 42.0000 21.0000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 21 34.000000 2550.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 13 19.000000 1425.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 11 18.500000 1387.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 38 59.500000 3302.2500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 22 25.500000 1912.5000 75.0000
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 5 5.000000 1400.0000 280.0000
Subtotal (Total Children Is Unduplicated) 62 166.500000 12047.7000 72.3586
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Total 166.500000 12047.7000 72.3586
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Number of Children (Unduplicated) With at Least One Service 62
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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
0 0.000000 0.0000 0.0000
Other 5 5.000000 70.4500 0.0000
---------------------------------------------------------
Total 5 5.000000 70.4500 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 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
26 23.500000 2612.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 26 23.500000 2612.0000 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 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
46 73.000000 5094.7500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 46 73.000000 5094.7500 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
38 65.000000 4270.5000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 38 65.000000 4270.5000 0.0000