CMS/EIP Fiscal Report Statewide
Services beginning 07/01/2012 ending 09/30/2012 Date of Report:11/15/2012 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 842 3373.250000 124773.2500 36.9890
Subtotal (Total Children Is Unduplicated) 842 3373.250000 124773.2500 36.9890
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Screening, Eval, and Assessment,Class #02
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 1 1.000000 9.1100 9.1100
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 1 1.000000 21.7300 21.7300
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 20 31.000000 2325.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 11 13.000000 975.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 7 8.500000 637.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 6 12.000000 900.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 36 58.500000 3246.7500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 244 373.000000 27975.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 122 189.000000 14175.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 77 103.000000 7725.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 440 687.000000 38128.5000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 141 248.000000 18600.0000 75.0000
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 44 44.000000 2227.7200 50.6300
SCREEN-T1023-INTERDISCIPLINARY SCREENING 7 7.000000 350.0000 50.0000
Subtotal (Total Children Is Unduplicated) 593 1776.000000 117296.3100 66.0452
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EI Services,Class #03
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 2 4.000000 271.5200 67.8800
Subtotal (Total Children Is Unduplicated) 2 4.000000 271.5200 67.8800
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Total 5153.250000 242341.0800 47.0268
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Number of Children (Unduplicated) With at Least One Service 863
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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 140 136.750000 6027.5000 0.0000
P 96 85.750000 3413.2500 3413.2500
D 2 1.000000 37.0000 0.0000
S 6 4.750000 175.7500 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
13 15.750000 1008.0000 0.0000
Other 43 72.000000 4941.7500 0.0000
---------------------------------------------------------
Total 300 316.000000 15603.2500 3413.2500
Center 02
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 107 93.250000 3441.0000 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
37 47.000000 2731.7500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 144 140.250000 6172.7500 0.0000
Center 03
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 10 13.500000 838.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 56 64.750000 3149.2500 0.0000
P 452 378.250000 16069.2500 16030.2500
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
1 1.500000 55.5000 0.0000
Other 3 2.500000 49.3400 0.0000
---------------------------------------------------------
Total 522 460.500000 20161.8400 16030.2500
Center 04
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 80 150.500000 5577.7500 0.0000
P 242 367.750000 15209.4100 15237.2500
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
68 64.500000 3321.3100 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 390 582.750000 24108.4700 15237.2500
Center 07
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 2 1.000000 37.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 14 12.250000 453.2500 0.0000
P 247 276.500000 13367.2500 13367.2500
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
22 40.500000 2844.5000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 285 330.250000 16702.0000 13367.2500
Center 09
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 439 680.250000 35559.2500 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
4 9.000000 653.6400 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 443 689.250000 36212.8900 0.0000
Center 10
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 2 2.750000 101.7500 0.0000
U 0 0.000000 0.0000 0.0000
B 763 860.000000 39624.7500 0.0000
P 327 366.500000 17832.2500 17832.2500
D 0 0.000000 0.0000 0.0000
S 2 3.000000 111.0000 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 1094 1232.250000 57669.7500 17832.2500
Center 51
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 19 26.750000 1102.2500 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
3 3.500000 262.5000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 22 30.250000 1364.7500 0.0000
Center 53
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 9 9.000000 409.0000 0.0000
P 309 385.250000 15909.5000 15909.5000
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
32 59.000000 4210.5000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 350 453.250000 20529.0000 15909.5000
Center 54
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 42 56.000000 3643.5000 0.0000
P 379 340.750000 13645.7500 13645.7500
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
49 76.500000 4840.5000 0.0000
Other 1 1.500000 55.5000 0.0000
---------------------------------------------------------
Total 471 474.750000 22185.2500 13645.7500
Center 55
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 1 0.750000 27.7500 0.0000
P 166 180.000000 7287.0000 7287.0000
D 0 0.000000 0.0000 0.0000
S 3 2.000000 74.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
38 61.500000 4498.6300 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 208 244.250000 11887.3800 7287.0000
Center 57
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 72 104.500000 4016.5000 0.0000
P 74 95.000000 5727.2500 5727.2500
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 146 199.500000 9743.7500 5727.2500