CMS/EIP Fiscal Report Statewide
Services beginning 01/01/2012 ending 03/31/2012 Date of Report:05/16/2012 Page: 1
List order: No List
Payclass Filters:MED
Eligibility Filter:Program Patients
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 12693 46675.50000 1725395.2500 36.9658
Subtotal (Total Children Is Unduplicated) 12693 46675.50000 1725395.2500 36.9658
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Screening, Eval, and Assessment,Class #02
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 87 90.000000 745.2000 8.2800
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 59 61.000000 633.1800 10.3800
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 88 91.000000 1918.2800 21.0800
AUDE-92582-CONDITIONED PLAY AUDIOMETRY 1 1.000000 22.9600 22.9600
AUDE-92585-AUD EVOKED RESPONSE (DIAG) 1 1.000000 51.7600 51.7600
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 3 3.000000 81.5700 27.1900
BEHV-H0031HO-COMP BEHAVIORAL HEALTH ASSESSMENT 4 8.000000 1000.0000 125.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 147 241.500000 18112.5000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 36 52.000000 3900.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 33 49.000000 3675.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 78 139.000000 10425.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 187 309.500000 17166.2500 55.4645
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 1337 2028.000000 152100.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 477 760.500000 56962.5000 74.9014
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 315 453.000000 33950.0000 74.9448
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 1638 2573.000000 142746.0000 55.4784
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 828 1326.000000 99450.0000 75.0000
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 131 131.000000 11230.0000 85.7252
MED-99204-OUTPATIENT VISIT, NEW, 45 MINS 2 2.000000 114.5400 57.2700
MED-99205-OUTPATIENT VISIT, NEW, 60 MINS 1 1.000000 72.7800 72.7800
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 21 21.000000 879.2400 41.8686
MED-99214-OUTPATIENT VISIT, EST, 25 MINS 2 2.000000 69.0000 34.5000
MED-99215-OUTPATIENT VISIT, EST, 40 MINS 4 4.000000 200.6000 50.1500
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 45 48.000000 2328.0000 48.5000
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 48 49.000000 2376.5000 48.5000
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 28 28.000000 1358.0000 48.5000
PSTH-97001-EVAL BY LICENSED PT, INITIAL 44 44.000000 2134.0000 48.5000
SCREEN-T1023-INTERDISCIPLINARY SCREENING 106 106.000000 5300.0000 50.0000
SPCH-92506-SPEECH EVAL BY LICENSED SLP 116 117.000000 5674.5000 48.5000
Subtotal (Total Children Is Unduplicated) 3011 8739.500000 574677.3600 65.7563
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 2 2.000000 1928.0000 964.0000
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 19 50.000000 1250.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 4214 31007.50000 1550200.0000 49.9944
HERN-T1027SC-EI HEARING SERVICES AFTER SHINE 28 135.000000 6750.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 476 2496.750000 169425.1500 67.8583
OCCT-97530HM-OT SESSION BY OT ASST 28 161.500000 8772.6800 54.3200
PHY-97110-PT SESSION BY LICENSED PT 675 3565.000000 241937.9600 67.8648
PHY-97110HM-PT SESSION BY PT ASST 56 246.250000 13376.3000 54.3200
SHIN-T1027SC-INITIAL SHINE SERVICES, INDIVIDUAL 13 19.000000 950.0000 50.0000
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 915 4868.048600 330388.4600 67.8688
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 3 6.000000 325.9200 54.3200
SPL-92508-GROUP SPL SESSION PER CHILD 7 15.750000 207.9000 13.2000
VISN-T1027SC-EI VISION SERVICES, INDIVIDUAL 7 17.000000 850.0000 50.0000
Subtotal (Total Children Is Unduplicated) 5337 42589.79860 2326362.3700 54.6225
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Total 98004.798600 4626434.9800 47.2062
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Number of Children (Unduplicated) With at Least One Service 13277
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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 62 48.750000 1803.7500 0.0000
P 5906 4624.750000 182023.5000 200253.2500
D 111 67.000000 2518.0000 0.0000
S 44 26.500000 980.5000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
1723 3438.250000 176366.0700 0.0000
Other 273 383.500000 26513.1800 0.0000
---------------------------------------------------------
Total 8119 8588.750000 390205.0000 200253.2500
Center 02
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 1309 1053.000000 38655.7500 0.0000
P 0 0.000000 0.0000 0.0000
D 0 0.000000 0.0000 0.0000
S 1 0.500000 18.5000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
150 248.250000 16769.2500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 1460 1301.750000 55443.5000 0.0000
Center 03
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 9 5.000000 185.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 373 200.000000 8225.2600 0.0000
P 4711 2958.500000 119532.7500 120494.7310
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 105 104.750000 1572.5800 0.0000
---------------------------------------------------------
Total 5198 3268.250000 129515.5900 120494.7310
Center 04
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 2 0.500000 18.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 1287 1288.250000 50488.0000 0.0000
P 4609 4885.750000 192922.7000 187874.0100
D 2 5.000000 250.0000 250.0000
S 0 0.000000 0.0000 0.0000
H 1850 6097.000000 309475.0400 309563.2600
T 0 0.000000 0.0000 0.0000
394 677.750000 42745.5100 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 8144 12954.250000 595899.7500 497687.2700
Center 05
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 1832 1091.500000 41718.6300 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
9 7.500000 486.5000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 1841 1099.000000 42205.1300 0.0000
Center 06
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 1 0.500000 18.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 23 12.750000 471.7500 18.5000
P 3963 2782.500000 102952.5000 64777.7500
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
2820 2706.500000 149245.5200 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 6807 5502.250000 252688.2700 64796.2500
Center 07
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 37 24.250000 897.2500 0.0000
P 5498 3986.500000 159328.5000 159300.7500
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
1255 3444.750000 177671.4900 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 6790 7455.500000 337897.2400 159300.7500
Center 09
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 4833 4867.250000 221074.8000 175.7500
P 1860 1816.500000 75271.5000 74984.5000
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
1596 4756.750000 273482.3900 0.0000
Other 1 2.000000 111.0000 111.0000
---------------------------------------------------------
Total 8290 11442.500000 569939.6900 75271.2500
Center 10
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 5052 3935.000000 172314.5000 0.0000
P 5265 3846.750000 152720.2500 152220.2500
D 18 24.750000 1789.7500 1771.2500
S 151 80.250000 2969.2500 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
1751 4700.000000 268326.5100 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 12237 12586.750000 598120.2600 153991.5000
Center 51
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 4043 3040.250000 120441.2500 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
1004 2795.250000 167030.9400 0.0000
Other 31 30.500000 2050.9600 0.0000
---------------------------------------------------------
Total 5078 5866.000000 289523.1500 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 98 76.250000 4201.5800 0.0000
P 2502 1769.500000 77549.6200 77452.6200
D 0 0.000000 0.0000 0.0000
S 49 61.250000 4396.5700 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
373 982.000000 61194.6000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 3022 2889.000000 147342.3700 77452.6200
Center 53
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 1 0.500000 18.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 678 785.000000 31469.5000 0.0000
P 1840 1739.000000 73608.5000 73534.5000
D 221 205.750000 8526.5000 0.0000
S 514 430.500000 17134.7500 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
2766 2814.000000 154262.5200 271.5200
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 6020 5974.750000 285020.2700 73806.0200
Center 54
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 37 29.500000 1091.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 1663 1209.000000 50455.0000 0.0000
P 3754 2589.000000 105568.7500 104107.2500
D 4 1.250000 46.2500 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
2747 2793.048600 156355.3400 0.0000
Other 70 61.750000 3359.2500 0.0000
---------------------------------------------------------
Total 8275 6683.548600 316876.0900 104107.2500
Center 55
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 32 33.000000 1221.0000 0.0000
P 1897 1843.750000 71925.0000 71925.0000
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
2192 1905.500000 121154.9500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 4121 3782.250000 194300.9500 71925.0000
Center 57
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 40 32.250000 1193.2500 0.0000
U 0 0.000000 0.0000 0.0000
B 1425 1348.500000 51818.0000 0.0000
P 1555 1729.500000 75538.7500 75511.0000
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 2 9.000000 450.0000 450.0000
1672 5491.000000 292457.7200 292417.6200
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 4694 8610.250000 421457.7200 368378.6200