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
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 10595 33215.00000 1227118.2500 36.9447
Subtotal (Total Children Is Unduplicated) 10595 33215.00000 1227118.2500 36.9447
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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) 45 46.000000 407.4400 8.8574
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 24 25.000000 240.7800 9.6312
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 44 45.000000 968.7500 21.5278
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 2 2.000000 48.9400 24.4700
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 104 172.000000 12900.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 34 50.000000 3750.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 27 32.500000 2437.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 39 67.000000 5025.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 167 275.000000 15262.5000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 876 1358.000000 101812.5000 74.9724
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 401 664.000000 49762.5000 74.9435
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 293 385.000000 28875.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 1469 2314.500000 128454.7500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 629 1087.000000 81486.0000 74.9641
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 147 147.000000 7442.6100 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 66 66.000000 3300.0000 50.0000
SPCH-92506-SPEECH EVAL BY LICENSED SLP 80 80.000000 3880.0000 48.5000
Subtotal (Total Children Is Unduplicated) 2383 6953.000000 452140.8000 65.0282
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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 607 2908.471400 197317.6800 67.8424
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) 4787 36239.87080 1937245.7000 53.4562
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Total 76407.870800 3616504.7500 47.3316
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Number of Children (Unduplicated) With at Least One Service 11368
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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 94 76.250000 2834.2500 0.0000
S 156 103.000000 3811.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
1318 3091.750000 163243.9000 0.0000
Other 205 350.000000 23825.5000 0.0000
---------------------------------------------------------
Total 6845 7228.750000 334963.9000 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 1 1.000000 37.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
357 404.000000 23135.7500 0.0000
Other 1 0.500000 18.5000 0.0000
---------------------------------------------------------
Total 1545 1406.250000 59765.7500 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
2 1.750000 64.7500 0.0000
Other 123 123.250000 1839.9400 0.0000
---------------------------------------------------------
Total 3904 2662.500000 104445.9400 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 2110 6818.500000 345395.1200 327605.7200
T 0 0.000000 0.0000 0.0000
654 832.000000 43974.3800 0.0000
Other 4 3.500000 129.5000 0.0000
---------------------------------------------------------
Total 7403 13108.750000 598295.7600 468171.3200
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 1 0.500000 18.5000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
1252 3447.000000 177178.2500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 5407 6438.000000 299123.0000 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
1755 5251.750000 295875.1300 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 7610 11023.750000 553064.3500 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 40 27.500000 1017.5000 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 10783 11749.000000 558053.5800 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 790 591.500000 23486.5000 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
311 993.750000 59312.9500 0.0000
Other 5 7.000000 475.1600 0.0000
---------------------------------------------------------
Total 1107 1594.500000 83357.8600 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
1907 1964.000000 104695.5300 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 5174 5055.500000 233350.2800 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 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
2525 2517.870800 138071.5200 0.0000
Other 20 9.500000 351.5000 0.0000
---------------------------------------------------------
Total 7596 6127.870800 291432.0000 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 39 20.500000 712.2500 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
2193 1995.750000 126344.5600 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 3979 3778.750000 195847.3100 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 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 3333 6234.250000 304805.0200 252089.5300