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:Program Patients
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 11638 40043.00000 1480238.2500 36.9662
Subtotal (Total Children Is Unduplicated) 11638 40043.00000 1480238.2500 36.9662
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Screening, Eval, and Assessment,Class #02
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 45 45.000000 372.6000 8.2800
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 29 30.000000 311.4000 10.3800
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 44 44.000000 927.5200 21.0800
AUDE-92585-AUD EVOKED RESPONSE (DIAG) 3 4.000000 207.0400 51.7600
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 1 1.000000 27.1900 27.1900
BEHV-H0031HO-COMP BEHAVIORAL HEALTH ASSESSMENT 1 2.000000 250.0000 125.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 120 194.000000 14512.5000 74.8067
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 30 53.000000 3975.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 38 52.000000 3900.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 53 89.000000 6675.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 196 328.500000 18231.7500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 1168 1808.500000 135600.0000 74.9793
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 394 659.500000 49387.5000 74.8863
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 313 430.500000 32287.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 1566 2458.000000 136419.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 643 1145.500000 85836.5000 74.9337
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 145 145.000000 5872.5000 40.5000
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 23 23.000000 509.2200 22.1400
MED-99214-OUTPATIENT VISIT, EST, 25 MINS 2 2.000000 69.0000 34.5000
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 23 24.000000 1164.0000 48.5000
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 35 35.000000 1697.5000 48.5000
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 27 27.000000 1309.5000 48.5000
PSTH-97001-EVAL BY LICENSED PT, INITIAL 38 38.000000 1843.0000 48.5000
SCREEN-T1023-INTERDISCIPLINARY SCREENING 118 118.000000 5900.0000 50.0000
SPCH-92506-SPEECH EVAL BY LICENSED SLP 83 86.000000 4171.0000 48.5000
Subtotal (Total Children Is Unduplicated) 2685 7842.500000 511456.2200 65.2160
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 3 11.000000 4255.7900 386.8900
COUN-H2019HR-INDIVIDUAL/FAMILY THERAPY 4 10.000000 696.5400 69.6540
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 22 62.000000 1550.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 4369 31279.75000 1563789.5000 49.9937
HERN-T1027SC-EI HEARING SERVICES AFTER SHINE 20 61.500000 3075.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 395 2150.532034 145901.6100 67.8444
OCCT-97530HM-OT SESSION BY OT ASST 20 110.500000 6002.3600 54.3200
PHY-97110-PT SESSION BY LICENSED PT 662 3266.211280 221710.0100 67.8799
PHY-97110HM-PT SESSION BY PT ASST 41 169.000000 9180.0800 54.3200
SHIN-T1027SC-INITIAL SHINE SERVICES, INDIVIDUAL 14 26.500000 1325.0000 50.0000
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 776 4109.635600 278962.0700 67.8800
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 6 18.000000 977.7600 54.3200
SPL-92508-GROUP SPL SESSION PER CHILD 8 11.250000 148.5000 13.2000
VISN-T1027SC-EI VISION SERVICES, INDIVIDUAL 4 28.000000 1400.0000 50.0000
Subtotal (Total Children Is Unduplicated) 5439 41313.87891 2238974.2200 54.1942
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Total 89199.378914 4230668.6900 47.4294
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Number of Children (Unduplicated) With at Least One Service 12392
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Center 01
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 209 163.250000 6040.2500 0.0000
U 0 0.000000 0.0000 0.0000
B 3350 2524.250000 94846.2500 0.0000
P 2410 1995.750000 77598.5000 77598.5000
D 109 92.250000 3413.2500 0.0000
S 187 207.000000 10428.7500 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
2394 3603.500000 189696.1000 0.0000
Other 190 292.000000 20978.3200 0.0000
---------------------------------------------------------
Total 8849 8878.000000 403001.4200 77598.5000
Center 02
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 1 0.250000 9.2500 0.0000
U 0 0.000000 0.0000 0.0000
B 959 810.500000 29840.5000 0.0000
P 0 0.000000 0.0000 0.0000
D 1 0.500000 18.5000 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
384 423.500000 23171.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 1345 1234.750000 53039.2500 0.0000
Center 03
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 5 5.250000 251.2500 0.0000
U 0 0.000000 0.0000 0.0000
B 583 404.000000 15873.0000 18.5000
P 3358 2233.500000 91166.7500 91065.0250
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
6 6.250000 231.2500 0.0000
Other 86 84.250000 1372.6400 0.0000
---------------------------------------------------------
Total 4038 2733.250000 108894.8900 91083.5250
Center 04
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 741 894.250000 33438.0000 0.0000
P 5022 5452.500000 210429.5900 210925.2500
D 66 83.000000 3071.0000 3071.0000
S 0 0.000000 0.0000 0.0000
H 2028 6681.750000 340010.0700 301718.3700
T 0 0.000000 0.0000 0.0000
398 595.000000 34536.6000 0.0000
Other 2 3.500000 237.5800 0.0000
---------------------------------------------------------
Total 8257 13710.000000 621722.8400 515714.6200
Center 06
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 937 645.750000 23892.7500 138.7500
P 401 260.750000 9647.7500 9592.2500
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
1073 1017.500000 54756.6800 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 2411 1924.000000 88297.1800 9731.0000
Center 07
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 40 27.250000 1047.2500 0.0000
U 0 0.000000 0.0000 0.0000
B 20 13.000000 481.0000 0.0000
P 5083 3696.250000 149015.7500 149015.7500
D 0 0.000000 0.0000 0.0000
S 1 1.250000 46.2500 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
1300 3638.250000 187377.3600 0.0000
Other 1 0.750000 27.7500 0.0000
---------------------------------------------------------
Total 6445 7376.750000 337995.3600 149015.7500
Center 09
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 5717 5703.500000 254527.8000 0.0000
P 288 369.500000 20529.7500 20904.2500
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
1689 5049.250000 286904.9600 0.0000
Other 1 1.000000 37.0000 0.0000
---------------------------------------------------------
Total 7695 11123.250000 561999.5100 20904.2500
Center 10
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 77 54.750000 2025.7500 0.0000
U 0 0.000000 0.0000 0.0000
B 8146 6004.250000 235539.5000 0.0000
P 905 1076.250000 61812.5000 61812.5000
D 2 0.750000 27.7500 27.7500
S 43 23.500000 869.5000 0.0000
H 2 5.750000 212.7500 0.0000
T 1 0.500000 18.5000 0.0000
2026 5625.250000 317376.7400 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 11202 12791.000000 617882.9900 61840.2500
Center 51
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 3558 2628.500000 104373.5000 0.0000
P 3 12.000000 600.0000 200.0000
D 1 1.000000 75.0000 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
805 2402.750000 142009.4100 0.0000
Other 18 29.500000 1964.5100 0.0000
---------------------------------------------------------
Total 4385 5073.750000 249022.4200 200.0000
Center 52
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 51 37.750000 2526.7900 0.0000
P 975 759.750000 33700.3900 33700.3900
D 0 0.000000 0.0000 0.0000
S 2 4.000000 261.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
138 330.440000 20207.8700 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 1166 1131.940000 56696.0500 33700.3900
Center 53
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 2 2.500000 133.2500 0.0000
U 0 0.000000 0.0000 0.0000
B 755 642.250000 23834.5000 37.0000
P 2210 2213.000000 94784.7500 94747.2500
D 1 2.000000 150.0000 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
2424 2470.500000 134391.1700 0.0000
Other 38 42.500000 2400.0000 0.0000
---------------------------------------------------------
Total 5430 5372.750000 255693.6700 94784.2500
Center 54
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 2 3.000000 161.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 1367 1078.000000 47028.2500 0.0000
P 3740 2756.250000 111138.2500 129086.5000
D 2 0.750000 27.7500 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
2681 2725.206800 153250.6100 0.0000
Other 65 77.500000 4801.5000 9.2500
---------------------------------------------------------
Total 7857 6640.706800 316407.3600 129095.7500
Center 55
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 31 22.750000 841.7500 0.0000
P 1491 1573.250000 61862.7500 61862.7500
D 0 0.000000 0.0000 0.0000
S 1 0.750000 27.7500 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
2114 1897.232114 120743.3100 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 3637 3493.982114 183475.5600 61862.7500
Center 57
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 52 67.000000 2544.7500 0.0000
U 0 0.000000 0.0000 0.0000
B 1483 1491.750000 57415.2500 112.5000
P 987 990.250000 45679.2500 45608.0000
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 3 3.750000 233.7500 0.0000
T 7 20.000000 1000.0000 1000.0000
1482 5142.500000 269667.1900 269668.6300
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 4014 7715.250000 376540.1900 316389.1300