CMS/EIP Fiscal Report Statewide
Services beginning 04/01/2012 ending 06/30/2012 Date of Report:08/16/2012 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 969 4233.250000 156463.7500 36.9607
Subtotal (Total Children Is Unduplicated) 969 4233.250000 156463.7500 36.9607
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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) 2 2.000000 20.7600 10.3800
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 3 3.000000 63.2400 21.0800
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 30 46.500000 3487.5000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 12 22.500000 1687.5000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 5 6.000000 450.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 16 26.000000 1950.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 42 77.500000 4301.2500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 374 549.000000 41137.5000 74.9317
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 132 202.000000 15112.5000 74.8144
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 93 119.000000 8925.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 489 744.500000 41319.7500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 160 262.000000 19650.0000 75.0000
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 31 31.000000 1255.5000 40.5000
SCREEN-T1023-INTERDISCIPLINARY SCREENING 12 12.000000 600.0000 50.0000
Subtotal (Total Children Is Unduplicated) 717 2106.000000 139985.3400 66.4698
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 4 26.000000 1300.0000 50.0000
Subtotal (Total Children Is Unduplicated) 4 26.000000 1300.0000 50.0000
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Total 6365.250000 297749.0900 46.7773
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Number of Children (Unduplicated) With at Least One Service 986
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Center 01
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 19 19.000000 703.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 178 144.500000 5543.7500 0.0000
P 123 134.000000 5691.5000 5691.5000
D 8 8.500000 314.5000 0.0000
S 14 16.500000 954.2500 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
23 25.500000 1565.0000 0.0000
Other 34 48.000000 3483.0000 0.0000
---------------------------------------------------------
Total 399 396.000000 18255.0000 5691.5000
Center 02
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 100 112.750000 4171.7500 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
74 104.250000 6433.7500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 174 217.000000 10605.5000 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 49 46.500000 1947.0000 0.0000
P 389 357.750000 16051.0000 16049.5200
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 8 8.000000 108.8400 0.0000
---------------------------------------------------------
Total 446 412.250000 18106.8400 16049.5200
Center 04
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 71 115.500000 4368.0000 0.0000
P 381 561.750000 23441.5000 23602.7000
D 1 4.750000 175.7500 175.7500
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 27.000000 1262.2500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 483 709.000000 29247.5000 23778.4500
Center 06
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 19 24.000000 888.0000 0.0000
P 13 14.000000 518.0000 518.0000
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
32 36.750000 2476.2500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 64 74.750000 3882.2500 518.0000
Center 07
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 3 1.500000 55.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 0 0.000000 0.0000 0.0000
P 211 229.500000 10203.7500 10203.7500
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
17 31.500000 2167.5000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 231 262.500000 12426.7500 10203.7500
Center 09
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 420 692.750000 36591.2500 0.0000
P 48 73.750000 4480.7500 4425.2500
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
0 0.000000 0.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 468 766.500000 41072.0000 4425.2500
Center 10
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 3 3.250000 120.2500 0.0000
U 0 0.000000 0.0000 0.0000
B 898 970.500000 39652.0000 0.0000
P 247 377.250000 22681.7500 22681.7500
D 0 0.000000 0.0000 0.0000
S 7 7.250000 268.2500 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 1155 1358.250000 62722.2500 22681.7500
Center 51
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 267 268.000000 10852.0000 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
18 32.000000 2100.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 285 300.000000 12952.0000 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 1 2.000000 150.0000 0.0000
P 81 110.750000 5708.5000 5708.5000
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
3 4.500000 337.5000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 85 117.250000 6196.0000 5708.5000
Center 53
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 1 1.500000 83.2500 0.0000
U 0 0.000000 0.0000 0.0000
B 80 89.000000 3313.0000 0.0000
P 260 326.750000 14470.7500 14470.7500
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
29 52.000000 3836.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 370 469.250000 21703.0000 14470.7500
Center 54
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 159 150.500000 6575.7500 0.0000
P 438 423.250000 17309.2500 17309.2500
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
61 87.000000 6146.7500 0.0000
Other 17 28.500000 2042.5000 0.0000
---------------------------------------------------------
Total 675 689.250000 32074.2500 17309.2500
Center 55
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 6 5.750000 212.7500 0.0000
P 230 292.000000 11870.0000 11870.0000
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
57 89.500000 6510.7500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 293 387.250000 18593.5000 11870.0000
Center 57
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 63 96.000000 3956.2500 0.0000
P 89 105.500000 5693.5000 5693.5000
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 1 1.500000 112.5000 0.0000
T 0 0.000000 0.0000 0.0000
1 3.000000 150.0000 150.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 154 206.000000 9912.2500 5843.5000