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
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 6 13.000000 481.0000 37.0000
Subtotal (Total Children Is Unduplicated) 6 13.000000 481.0000 37.0000
-----------------------------------------------------------------------------------------------------------------------
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
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 27 47.000000 3525.0000 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 19 33.000000 2475.0000 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
Subtotal (Total Children Is Unduplicated) 113 289.500000 22210.8000 76.7212
-----------------------------------------------------------------------------------------------------------------------
EI Services,Class #03
OCCT-97530-OT SESSION BY LICENSED OT 1 1.000000 67.8800 67.8800
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 25 53.000000 3597.6400 67.8800
Subtotal (Total Children Is Unduplicated) 26 54.000000 3665.5200 67.8800
-----------------------------------------------------------------------------------------------------------------------
Total 356.500000 26357.3200 73.9336
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 145
-----------------------------------------------------------------------------------------------------------------------
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 4 4.000000 1020.0000 826.0700
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
52 47.500000 6060.5000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 56 51.500000 7080.5000 826.0700
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
125 169.000000 11549.5200 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 125 169.000000 11549.5200 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
61 103.000000 6964.5000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 61 103.000000 6964.5000 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 0 0.000000 0.0000 0.0000
16 13.000000 481.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 16 13.000000 481.0000 0.0000