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
Agency Filter:EIP DEI DEIP
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 9631 29538.00000 1091106.2500 36.9391
Subtotal (Total Children Is Unduplicated) 9631 29538.00000 1091106.2500 36.9391
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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 63 109.000000 8175.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 22 35.000000 2625.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 17 20.000000 1500.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 25 44.000000 3300.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 111 182.500000 10128.7500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 386 574.500000 43087.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 214 359.500000 26962.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 195 253.000000 18975.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 878 1359.500000 75452.2500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 366 588.000000 44061.0000 74.9337
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
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 59 59.000000 2950.0000 50.0000
SPCH-92506-SPEECH EVAL BY LICENSED SLP 1 1.000000 48.5000 48.5000
Subtotal (Total Children Is Unduplicated) 1450 3843.000000 245448.9900 63.8691
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EI Services,Class #03
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 6 8.000000 200.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 316 1556.750000 77812.5000 49.9839
HERN-T1027SC-EI HEARING SERVICES AFTER SHINE 18 43.750000 2187.5000 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 14 58.000000 3937.0400 67.8800
Subtotal (Total Children Is Unduplicated) 385 1834.750000 95146.6100 51.8581
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Total 35215.750000 1431701.8500 40.6552
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Number of Children (Unduplicated) With at Least One Service 9694
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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
38 22.250000 823.2500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 4995 3473.500000 134897.7500 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
199 136.500000 5033.5000 0.0000
Other 1 0.500000 18.5000 0.0000
---------------------------------------------------------
Total 1280 1045.500000 38222.5000 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 1286 1620.250000 60060.7500 0.0000
P 2782 3121.750000 120674.3500 120718.1000
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
320 312.500000 15021.2900 0.0000
Other 4 3.500000 129.5000 0.0000
---------------------------------------------------------
Total 4392 5058.000000 195885.8900 120718.1000
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
27 16.000000 592.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 3919 2717.250000 108679.2500 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
0 0.000000 0.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 5416 5091.750000 221629.9700 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 2582 1819.500000 76037.0000 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
6 7.500000 390.5000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 8014 5550.250000 229270.0000 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
1 1.000000 50.0000 0.0000
Other 5 7.000000 475.1600 0.0000
---------------------------------------------------------
Total 778 575.000000 22992.6600 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
34 37.750000 1386.7500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 2981 2733.750000 113676.7500 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
113 75.250000 3472.2500 0.0000
Other 19 8.000000 296.0000 0.0000
---------------------------------------------------------
Total 4760 3286.500000 139469.4800 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
88 77.250000 3664.2500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 1693 1667.750000 65417.5000 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 0 0.000000 0.0000 0.0000
8 13.000000 867.7500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 1932 1814.500000 77276.0000 28769.7500