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: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 6 13.000000 481.0000 37.0000
Subtotal (Total Children Is Unduplicated) 6 13.000000 481.0000 37.0000
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Screening, Eval, and Assessment,Class #02
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 8 8.000000 80.1600 10.0200
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 4 4.000000 33.6400 8.4100
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 8 8.000000 168.0000 21.0000
AUDE-V5010-ASSESSMENT FOR HEARING AID 1 1.000000 35.9200 35.9200
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 2 3.000000 225.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 2 2.500000 187.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 5 5.000000 375.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 6 7.500000 416.2500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 35 61.000000 4575.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 18 24.500000 1837.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 27 47.000000 3525.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 55 85.500000 4745.2500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 36 43.500000 3262.5000 75.0000
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 14 14.000000 3920.0000 280.0000
MED-99204-OUTPATIENT VISIT, NEW, 45 MINS 1 1.000000 420.0000 420.0000
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 3 3.000000 540.0000 180.0000
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 11 11.000000 517.6000 47.0545
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 1 1.000000 48.5000 48.5000
PSTH-97001-EVAL BY LICENSED PT, INITIAL 4 4.000000 194.0000 48.5000
SPCH-92506-SPEECH EVAL BY LICENSED SLP 20 20.000000 970.0000 48.5000
Subtotal (Total Children Is Unduplicated) 150 354.500000 26076.8200 73.5594
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 2 7.000000 4031.4500 575.9214
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 16 64.000000 3200.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 44 130.750000 8462.1200 64.7198
OCCT-97530HM-OT SESSION BY OT ASST 5 7.000000 352.6800 50.3829
PHY-97110-PT SESSION BY LICENSED PT 75 196.750000 12745.2400 64.7789
PHY-97110HM-PT SESSION BY PT ASST 4 12.000000 651.8400 54.3200
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 103 270.000000 18092.2200 67.0082
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 4 2.500000 135.8000 54.3200
Subtotal (Total Children Is Unduplicated) 214 690.000000 47671.3500 69.0889
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Total 1057.500000 74229.1700 70.1931
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Number of Children (Unduplicated) With at Least One Service 343
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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 20 20.000000 281.8000 0.0000
---------------------------------------------------------
Total 20 20.000000 281.8000 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 16 41.000000 3227.6000 1916.3300
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 1 1.000000 50.0000 0.0000
T 0 0.000000 0.0000 0.0000
52 47.500000 6060.5000 0.0000
Other 41 95.500000 6232.5800 5906.6600
---------------------------------------------------------
Total 110 185.000000 15570.6800 7822.9900
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
180 307.000000 20659.4800 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 180 307.000000 20659.4800 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
188 312.750000 23365.3800 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 188 312.750000 23365.3800 0.0000
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 16 36.500000 1914.3400 1914.3400
119 196.250000 12437.4900 11956.4900
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 135 232.750000 14351.8300 13870.8300