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:Part C (excluding not eligible)
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 9670 29640.50000 1094898.7500 36.9393
Subtotal (Total Children Is Unduplicated) 9670 29640.50000 1094898.7500 36.9393
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Screening, Eval, and Assessment,Class #02
AUDE-92553-PURE TONE AUDIOMETRY AIR & BONE 1 1.000000 16.7800 16.7800
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 44 45.000000 398.3300 8.8518
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 24 25.000000 240.7800 9.6312
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 43 44.000000 947.0200 21.5232
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 2 2.000000 48.9400 24.4700
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 84 141.000000 10575.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 23 37.000000 2775.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 20 24.000000 1800.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 33 55.000000 4125.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 131 216.500000 12015.7500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 632 985.000000 73837.5000 74.9619
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 279 475.000000 35587.5000 74.9211
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 216 282.000000 21150.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 1026 1624.500000 90159.7500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 483 831.000000 62286.0000 74.9531
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 103 103.000000 5214.8900 50.6300
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 33 33.000000 1074.4800 32.5600
MED-99214-OUTPATIENT VISIT, EST, 25 MINS 1 1.000000 48.2700 48.2700
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 14 14.000000 679.0000 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 9 9.000000 436.5000 48.5000
PSTH-97001-EVAL BY LICENSED PT, INITIAL 43 44.000000 2134.0000 48.5000
SCREEN-T1023-INTERDISCIPLINARY SCREENING 59 59.000000 2950.0000 50.0000
SPCH-92506-SPEECH EVAL BY LICENSED SLP 80 80.000000 3880.0000 48.5000
Subtotal (Total Children Is Unduplicated) 1785 5166.000000 334077.9900 64.6686
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 2 11.000000 4832.9000 439.3545
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 31 110.000000 2750.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 3969 28972.00000 1448476.0000 49.9957
HERN-T1027SC-EI HEARING SERVICES AFTER SHINE 18 43.750000 2187.5000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 307 1563.406800 106124.0700 67.8800
OCCT-97530HM-OT SESSION BY OT ASST 10 35.000000 1901.2000 54.3200
PHY-97110-PT SESSION BY LICENSED PT 495 2420.492600 164303.0500 67.8800
PHY-97110HM-PT SESSION BY PT ASST 35 137.250000 7455.4200 54.3200
SHIN-T1027SC-INITIAL SHINE SERVICES, INDIVIDUAL 9 23.000000 1150.0000 50.0000
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 605 2904.471400 197046.1600 67.8423
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 2 6.500000 353.0800 54.3200
SPL-92508-GROUP SPL SESSION PER CHILD 2 1.500000 19.8000 13.2000
VISN-T1027SC-EI VISION SERVICES, INDIVIDUAL 4 7.500000 375.0000 50.0000
Subtotal (Total Children Is Unduplicated) 4785 36235.87080 1936974.1800 53.4546
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Total 71042.370800 3365950.9200 47.3795
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Number of Children (Unduplicated) With at Least One Service 10422
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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 3161 2156.750000 85039.2500 0.0000
P 1559 1133.000000 43046.7500 44878.2500
D 88 64.750000 2408.7500 0.0000
S 149 96.750000 3579.7500 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
1301 3071.000000 161880.4000 0.0000
Other 162 278.000000 18883.7500 0.0000
---------------------------------------------------------
Total 6420 6800.250000 314838.6500 44878.2500
Center 02
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 1078 906.750000 33105.7500 0.0000
P 1 0.750000 27.7500 0.0000
D 0 0.000000 0.0000 0.0000
S 1 1.000000 37.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
320 357.000000 20404.0000 0.0000
Other 1 0.500000 18.5000 0.0000
---------------------------------------------------------
Total 1401 1266.000000 53593.0000 0.0000
Center 03
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 44 34.250000 1832.2500 0.0000
U 0 0.000000 0.0000 0.0000
B 268 213.250000 9048.0000 0.0000
P 2949 1833.500000 71604.0000 71605.5000
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
1 0.250000 9.2500 0.0000
Other 120 120.750000 1790.6000 0.0000
---------------------------------------------------------
Total 3382 2202.000000 84284.1000 71605.5000
Center 04
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 1325 1654.000000 61309.5000 0.0000
P 2854 3194.500000 123444.1000 123237.8500
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 2110 6818.500000 345395.1200 327605.7200
T 0 0.000000 0.0000 0.0000
585 767.250000 40643.8200 0.0000
Other 4 3.500000 129.5000 0.0000
---------------------------------------------------------
Total 6878 12437.750000 570922.0400 450843.5700
Center 07
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 12 5.500000 207.2500 0.0000
U 0 0.000000 0.0000 0.0000
B 416 284.500000 10639.5000 0.0000
P 3463 2410.750000 97222.0000 97222.0000
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
1230 3406.500000 174333.7500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 5122 6107.750000 282421.0000 97222.0000
Center 09
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 5416 5091.750000 221629.9700 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
1751 5242.750000 295221.4900 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 7167 10334.500000 516851.4600 0.0000
Center 10
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 54 24.000000 888.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 5334 3674.750000 151048.0000 0.0000
P 2583 1823.500000 76237.0000 76037.0000
D 0 0.000000 0.0000 0.0000
S 38 24.500000 906.5000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
1680 4970.000000 271304.3300 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 9689 10516.750000 500383.8300 76037.0000
Center 51
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 771 564.750000 22384.2500 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
308 990.250000 59050.4500 0.0000
Other 5 7.000000 475.1600 0.0000
---------------------------------------------------------
Total 1085 1564.250000 81993.1100 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 280 242.500000 10327.7500 9.2500
P 2666 2452.000000 101906.7500 101838.2500
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
1875 1905.000000 100485.0300 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 4822 4601.000000 212775.0300 101847.5000
Center 54
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 699 620.500000 31361.4800 0.0000
P 3926 2581.500000 104293.5000 104293.5000
D 3 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
2476 2441.370800 133231.0200 0.0000
Other 19 8.000000 296.0000 0.0000
---------------------------------------------------------
Total 7123 5652.620800 269228.2500 104293.5000
Center 55
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 15 12.250000 453.2500 0.0000
P 1554 1559.750000 60661.7500 60699.2500
D 0 0.000000 0.0000 0.0000
S 36 18.500000 638.2500 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
2155 1934.250000 121845.9300 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 3760 3524.750000 183599.1800 60699.2500
Center 57
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 58 42.750000 1581.7500 0.0000
U 0 0.000000 0.0000 0.0000
B 1350 1209.500000 45944.2500 0.0000
P 515 547.750000 28769.7500 28769.7500
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 1 3.000000 203.6400 203.6400
1262 4230.250000 218449.3800 217388.8900
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 3187 6034.750000 295061.2700 246362.2800