CMS/EIP Fiscal Report Statewide
Services beginning 01/01/2012 ending 03/31/2012 Date of Report:05/15/2012 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 1091 4754.750000 175629.7500 36.9377
Subtotal (Total Children Is Unduplicated) 1091 4754.750000 175629.7500 36.9377
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Screening, Eval, and Assessment,Class #02
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 5 5.000000 41.4000 8.2800
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 2 2.000000 20.7600 10.3800
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 5 5.000000 105.4000 21.0800
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 33 50.500000 3787.5000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 13 20.000000 1500.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 9 13.500000 1012.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 17 27.000000 2025.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 45 81.000000 4484.5000 55.3642
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 395 572.500000 42937.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 142 205.500000 15412.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 75 103.000000 7725.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 491 754.500000 41847.0000 55.4632
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 200 311.500000 23362.5000 75.0000
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 25 25.000000 2313.0000 92.5200
SCREEN-T1023-INTERDISCIPLINARY SCREENING 16 16.000000 800.0000 50.0000
Subtotal (Total Children Is Unduplicated) 748 2192.000000 147374.5600 67.2329
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 3 24.000000 1200.0000 50.0000
Subtotal (Total Children Is Unduplicated) 3 24.000000 1200.0000 50.0000
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Total 6970.750000 324204.3100 46.5092
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Number of Children (Unduplicated) With at Least One Service 1101
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Center 01
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 2 3.500000 129.5000 0.0000
P 478 445.750000 18713.2500 37044.7500
D 4 1.500000 55.5000 0.0000
S 10 8.500000 314.5000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
24 33.000000 2397.0000 0.0000
Other 54 77.500000 5783.2500 0.0000
---------------------------------------------------------
Total 572 569.750000 27393.0000 37044.7500
Center 02
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 126 129.750000 4773.0000 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
43 67.500000 4528.7500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 169 197.250000 9301.7500 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 36 31.000000 1231.7500 0.0000
P 517 442.000000 19665.2500 19712.5000
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
0 0.000000 0.0000 0.0000
Other 12 12.000000 167.5600 0.0000
---------------------------------------------------------
Total 565 485.000000 21064.5600 19712.5000
Center 04
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 95 134.250000 5594.5000 0.0000
P 349 509.250000 21786.7500 20815.6000
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
14 18.500000 871.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 458 662.000000 28252.2500 20815.6000
Center 05
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 40 36.500000 1464.5000 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
0 0.000000 0.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 40 36.500000 1464.5000 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 1 0.750000 27.7500 0.0000
P 151 150.000000 5550.0000 3172.7500
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
39 47.000000 3388.5000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 191 197.750000 8966.2500 3172.7500
Center 07
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 1 4.000000 148.0000 0.0000
P 319 342.750000 14821.7500 14821.7500
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
33 60.000000 4085.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 353 406.750000 19054.7500 14821.7500
Center 09
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 385 587.750000 31887.0000 0.0000
P 143 218.250000 10542.2500 10467.2500
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
2 4.000000 261.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 530 810.000000 42690.2500 10467.2500
Center 10
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 567 619.250000 30793.5000 0.0000
P 495 546.250000 23122.7500 23122.7500
D 3 3.500000 262.5000 262.5000
S 4 2.750000 101.7500 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 1069 1171.750000 54280.5000 23385.2500
Center 51
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 308 291.750000 11868.2500 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
23 26.000000 1950.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 331 317.750000 13818.2500 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 7 6.000000 279.0000 0.0000
P 197 192.500000 9041.0000 9041.0000
D 0 0.000000 0.0000 0.0000
S 7 13.000000 975.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
3 5.000000 375.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 214 216.500000 10670.0000 9041.0000
Center 53
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 95 136.750000 5337.7500 0.0000
P 238 293.250000 13062.5000 13044.0000
D 35 41.750000 1557.7500 0.0000
S 50 55.250000 2344.2500 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
49 82.000000 5740.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 467 609.000000 28042.2500 13044.0000
Center 54
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 6 7.750000 286.7500 0.0000
U 0 0.000000 0.0000 0.0000
B 180 151.000000 6289.0000 0.0000
P 447 336.750000 13308.2500 13289.7500
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
72 109.500000 7266.7500 0.0000
Other 8 12.000000 900.0000 0.0000
---------------------------------------------------------
Total 713 617.000000 28050.7500 13289.7500
Center 55
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 4 3.000000 111.0000 0.0000
P 242 276.000000 11034.5000 11034.5000
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
36 58.000000 4291.5000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 282 337.000000 15437.0000 11034.5000
Center 57
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 1 0.500000 18.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 122 134.000000 5533.7500 0.0000
P 139 189.250000 9516.0000 9516.0000
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
3 13.000000 650.0000 650.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 265 336.750000 15718.2500 10166.0000