CMS/EIP Fiscal Report Statewide
Services beginning 10/01/2012 ending 12/31/2012 Date of Report:02/16/2013 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 7074 20256.75000 748870.5000 36.9689
Subtotal (Total Children Is Unduplicated) 7074 20256.75000 748870.5000 36.9689
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 52 90.000000 6750.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 23 34.500000 2587.5000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 12 21.500000 1612.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 23 42.500000 3187.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 70 123.500000 6854.2500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 493 763.000000 57225.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 249 410.000000 30750.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 222 330.000000 24750.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 909 1496.000000 83028.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 288 394.500000 29587.5000 75.0000
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 16 16.000000 810.0800 50.6300
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 3 3.000000 97.6800 32.5600
SCREEN-T1023-SCREENING 1 1.000000 50.0000 50.0000
Subtotal (Total Children Is Unduplicated) 1265 3725.500000 247290.0100 66.3777
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EI Services,Class #03
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 3 6.000000 150.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 210 593.250000 29662.5000 50.0000
HERN-T1027SC-EI HEARING SERVICES AFTER SHINE 7 9.000000 450.0000 50.0000
PHY-97110-PT SESSION BY LICENSED PT 24 127.250000 8637.7300 67.8800
PHY-97110HM-PT SESSION BY PT ASST 1 5.000000 271.6000 54.3200
SHIN-T1027SC-INITIAL SHINE SERVICES, INDIVIDUAL 5 6.000000 300.0000 50.0000
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 33 94.000000 6380.7200 67.8800
Subtotal (Total Children Is Unduplicated) 276 840.500000 45852.5500 54.5539
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Total 24822.750000 1042013.0600 41.9781
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Number of Children (Unduplicated) With at Least One Service 7208
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Center 02
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 787 551.000000 20063.2500 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
0 0.000000 0.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 787 551.000000 20063.2500 0.0000
Center 03
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 12 7.500000 277.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 390 313.750000 14148.0000 0.0000
P 2160 1297.750000 53983.5000 54019.5000
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 2562 1619.000000 68409.0000 54019.5000
Center 04
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 25 34.500000 1276.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 999 1219.500000 47168.5000 0.0000
P 2501 2882.500000 109750.2600 109477.1200
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 3525 4136.500000 158195.2600 109477.1200
Center 09
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 2 2.500000 92.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 5859 5979.000000 265543.2600 0.0000
P 3 3.250000 120.2500 120.2500
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 5864 5984.750000 265756.0100 120.2500
Center 10
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 230 131.000000 4847.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 8376 6128.750000 262764.7500 0.0000
P 13 22.000000 1496.6300 1428.7500
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 8619 6281.750000 269108.3800 1428.7500
Center 53
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 2 2.250000 159.2500 0.0000
P 1162 1087.000000 45334.2500 45334.2500
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 1164 1089.250000 45493.5000 45334.2500
Center 54
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 196 209.250000 11584.4100 0.0000
P 1393 945.000000 37526.7500 37526.7500
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 1589 1154.250000 49111.1600 37526.7500
Center 55
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 59 66.750000 2526.7500 0.0000
P 1939 1877.000000 73350.2500 73350.2500
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 1998 1943.750000 75877.0000 73350.2500
Center 57
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 2 1.000000 37.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 1152 1090.250000 45684.7500 0.0000
P 872 971.250000 44277.7500 44277.7500
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 2026 2062.500000 89999.5000 44277.7500