CMS/EIP Fiscal Report Statewide
Services beginning 07/01/2012 ending 09/30/2012 Date of Report:11/16/2012 Page: 1
List order: No List
Payclass Filters:MED
Bill Flag Filter:RBPU
Eligibility Filter:All
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 10472 32583.25000 1203863.7500 36.9473
Subtotal (Total Children Is Unduplicated) 10472 32583.25000 1203863.7500 36.9473
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 75 128.000000 9600.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 32 46.500000 3487.5000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 20 25.000000 1875.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 30 53.500000 4012.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 133 222.500000 12348.7500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 549 828.000000 62100.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 310 503.500000 37762.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 225 316.000000 23700.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 1171 1876.000000 104118.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 470 755.500000 56623.5000 74.9484
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 15 15.000000 759.4500 50.6300
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 1 1.000000 32.5600 32.5600
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 1 1.000000 48.5000 48.5000
PSTH-97001-EVAL BY LICENSED PT, INITIAL 2 3.000000 145.5000 48.5000
SCREEN-T1023-INTERDISCIPLINARY SCREENING 66 66.000000 3300.0000 50.0000
SPCH-92506-SPEECH EVAL BY LICENSED SLP 1 1.000000 48.5000 48.5000
Subtotal (Total Children Is Unduplicated) 1827 4841.500000 319962.2600 66.0874
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EI Services,Class #03
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 5 5.000000 125.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 302 1471.750000 73562.5000 49.9830
HERN-T1027SC-EI HEARING SERVICES AFTER SHINE 18 41.750000 2087.5000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 5 22.750000 1544.2700 67.8800
PHY-97110-PT SESSION BY LICENSED PT 32 122.500000 8315.3000 67.8800
SHIN-T1027SC-INITIAL SHINE SERVICES, INDIVIDUAL 9 23.000000 1150.0000 50.0000
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 11 51.000000 3461.8800 67.8800
Subtotal (Total Children Is Unduplicated) 369 1737.750000 90246.4500 51.9329
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Total 39162.500000 1614072.4600 41.2147
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Number of Children (Unduplicated) With at Least One Service 10542
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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 3371 2343.000000 93087.2500 0.0000
P 1701 1264.750000 48162.0000 49993.5000
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 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 5072 3607.750000 141249.2500 49993.5000
Center 02
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 1185 1000.000000 36546.7500 0.0000
P 1 0.750000 27.7500 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 1186 1000.750000 36574.5000 0.0000
Center 03
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 54 47.750000 2670.7500 0.0000
U 0 0.000000 0.0000 0.0000
B 324 278.000000 12197.2500 0.0000
P 3401 2211.750000 87673.2500 87635.7500
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
0 0.000000 0.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 3779 2537.500000 102541.2500 87635.7500
Center 04
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 1444 1836.000000 68052.7500 0.0000
P 3191 3618.750000 140744.0100 140565.6000
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
0 0.000000 0.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 4635 5454.750000 208796.7600 140565.6000
Center 07
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 14 6.500000 244.2500 0.0000
U 0 0.000000 0.0000 0.0000
B 430 296.750000 11092.7500 0.0000
P 3710 2687.250000 110589.2500 110589.2500
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 4154 2990.500000 121926.2500 110589.2500
Center 09
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 5855 5772.000000 257189.2200 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 5855 5772.000000 257189.2200 0.0000
Center 10
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 56 26.750000 989.7500 0.0000
U 0 0.000000 0.0000 0.0000
B 6097 4534.750000 190672.7500 0.0000
P 2910 2190.000000 94069.2500 93869.2500
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 9063 6751.500000 285731.7500 93869.2500
Center 51
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 792 592.750000 23532.7500 0.0000
P 1 2.250000 83.2500 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 793 595.000000 23616.0000 0.0000
Center 53
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 1 1.500000 55.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 289 251.500000 10736.7500 9.2500
P 2977 2838.500000 117862.5000 117794.0000
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 3267 3091.500000 128654.7500 117803.2500
Center 54
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 741 676.500000 35004.9800 0.0000
P 4307 2922.750000 117957.7500 117957.7500
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
0 0.000000 0.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 5048 3599.250000 152962.7300 117957.7500
Center 55
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 16 13.000000 481.0000 0.0000
P 1731 1749.500000 68309.5000 68347.0000
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 1747 1762.500000 68790.5000 68347.0000
Center 57
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 58 42.750000 1581.7500 0.0000
U 0 0.000000 0.0000 0.0000
B 1422 1314.000000 49960.7500 0.0000
P 589 642.750000 34497.0000 34497.0000
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 2069 1999.500000 86039.5000 34497.0000