CMS/EIP Fiscal Report Statewide
Services beginning 10/01/2011 ending 12/31/2011 Date of Report:02/15/2012 Page: 1
List order: No List
Payclass Filters:MED
Eligibility Filter:Not Part C
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 1226 4587.500000 169072.5000 36.8550
Subtotal (Total Children Is Unduplicated) 1226 4587.500000 169072.5000 36.8550
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Screening, Eval, and Assessment,Class #02
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 3 3.000000 24.8400 8.2800
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 1 1.000000 10.3800 10.3800
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 3 3.000000 63.2400 21.0800
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 37 59.000000 4425.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 14 25.000000 1875.0000 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 12 21.000000 1575.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 37 66.000000 3663.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 393 575.000000 43125.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 166 241.500000 18112.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 96 137.500000 10312.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 498 753.000000 41783.2500 55.4890
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 195 299.000000 22425.0000 75.0000
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 36 36.000000 6515.5000 180.9861
PSTH-97001-EVAL BY LICENSED PT, INITIAL 1 1.000000 48.5000 48.5000
SCREEN-T1023-INTERDISCIPLINARY SCREENING 4 4.000000 200.0000 50.0000
Subtotal (Total Children Is Unduplicated) 767 2233.500000 154796.2100 69.3066
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 4 24.000000 1200.0000 50.0000
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 1 0.750000 50.9100 67.8800
Subtotal (Total Children Is Unduplicated) 5 24.750000 1250.9100 50.5418
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Total 6845.750000 325119.6200 47.4922
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Number of Children (Unduplicated) With at Least One Service 1237
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Center 01
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 1 0.500000 18.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 97 81.250000 3342.7500 0.0000
P 226 186.500000 7598.5000 7589.2500
D 10 11.000000 407.0000 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
8 25.500000 1318.0000 0.0000
Other 39 52.500000 3937.5000 0.0000
---------------------------------------------------------
Total 381 357.250000 16622.2500 7589.2500
Center 02
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 166 168.250000 6188.2500 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
56 81.750000 5801.5000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 222 250.000000 11989.7500 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 9 6.500000 411.5000 0.0000
P 328 275.000000 12645.0000 12648.0000
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 7 7.000000 98.4600 0.0000
---------------------------------------------------------
Total 344 288.500000 13154.9600 12648.0000
Center 04
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 218 307.750000 12260.7500 0.0000
P 255 356.500000 17814.7500 15410.0000
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
30 40.750000 3879.2500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 503 705.000000 33954.7500 15410.0000
Center 05
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 179 150.500000 6157.5000 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 20.000000 1500.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 195 170.500000 7657.5000 0.0000
Center 06
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 36 38.500000 1424.5000 0.0000
P 25 27.500000 1017.5000 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
20 27.500000 2062.5000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 81 93.500000 4504.5000 0.0000
Center 07
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 1 0.500000 18.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 21 11.000000 407.0000 0.0000
P 379 329.250000 13969.5000 13969.5000
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
24 40.000000 2575.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 425 380.750000 16970.0000 13969.5000
Center 09
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 642 1016.500000 53361.0000 0.0000
P 45 73.500000 2898.2500 2861.2500
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
1 1.250000 46.2500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 688 1091.250000 56305.5000 2861.2500
Center 10
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 4 3.000000 111.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 322 434.250000 26578.5000 1082.2500
P 706 591.000000 21867.0000 21867.0000
D 0 0.000000 0.0000 0.0000
S 8 11.250000 416.2500 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 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 1040 1039.500000 48972.7500 22949.2500
Center 51
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 229 225.000000 8948.5000 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
21 22.500000 1544.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 250 247.500000 10492.5000 0.0000
Center 52
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 57 60.750000 3403.2500 0.0000
P 192 203.000000 9090.0000 9090.0000
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
8 12.500000 937.5000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 257 276.250000 13430.7500 9090.0000
Center 53
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 7 7.500000 314.5000 0.0000
P 249 309.500000 12656.5000 12656.5000
D 9 18.000000 1350.0000 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
92 138.750000 7619.2500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 357 473.750000 21940.2500 12656.5000
Center 54
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 19 17.500000 647.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 4 5.000000 375.0000 0.0000
P 1 0.250000 9.2500 9.2500
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
700 694.000000 33085.6600 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 724 716.750000 34117.4100 9.2500
Center 55
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 15 16.500000 610.5000 0.0000
P 249 304.000000 12249.2500 12249.2500
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
54 94.250000 6952.5000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 318 414.750000 19812.2500 12249.2500
Center 57
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 8 13.250000 490.2500 0.0000
U 0 0.000000 0.0000 0.0000
B 182 222.000000 10226.5000 0.0000
P 60 84.250000 3117.2500 3117.2500
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
17 21.000000 1360.5000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 267 340.500000 15194.5000 3117.2500