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
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 679 2412.500000 89151.5000 36.9540
Subtotal (Total Children Is Unduplicated) 679 2412.500000 89151.5000 36.9540
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Screening, Eval, and Assessment,Class #02
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 7 7.000000 63.7700 9.1100
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 3 3.000000 28.0200 9.3400
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 7 7.000000 152.1100 21.7300
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 10 16.500000 1237.5000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 10 17.500000 1312.5000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 2 3.500000 262.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 1 2.000000 150.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 23 39.500000 2192.2500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 198 311.000000 23325.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 146 235.500000 17662.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 64 88.000000 6600.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 364 551.000000 30580.5000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 93 134.500000 10087.5000 75.0000
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 39 39.000000 1974.5700 50.6300
Subtotal (Total Children Is Unduplicated) 489 1455.000000 95628.7200 65.7242
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Total 3867.500000 184780.2200 47.7777
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Number of Children (Unduplicated) With at Least One Service 696
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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 104 101.750000 3672.2500 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
70 112.000000 6905.5000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 174 213.750000 10577.7500 0.0000
Center 03
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 77 86.500000 4393.7500 0.0000
P 372 320.000000 14757.0000 14763.7500
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 3.000000 225.0000 0.0000
Other 17 17.000000 243.9000 0.0000
---------------------------------------------------------
Total 468 426.500000 19619.6500 14763.7500
Center 04
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 66 113.000000 4509.7500 0.0000
P 189 319.750000 12407.8800 12398.6300
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
120 123.750000 6143.6900 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 375 556.500000 23061.3200 12398.6300
Center 09
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 438 717.250000 37204.0000 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
0 0.000000 0.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 438 717.250000 37204.0000 0.0000
Center 10
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 10 10.250000 379.2500 0.0000
U 0 0.000000 0.0000 0.0000
B 917 1027.250000 49132.7500 0.0000
P 3 4.500000 308.2500 308.2500
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 930 1042.000000 49820.2500 308.2500
Center 53
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 0 0.000000 0.0000 0.0000
P 94 114.750000 4984.0000 4984.0000
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
12 23.000000 1725.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 106 137.750000 6709.0000 4984.0000
Center 54
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 17 28.250000 1858.7500 0.0000
P 87 92.750000 3459.5000 3459.5000
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
34 46.750000 2982.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 138 167.750000 8300.2500 3459.5000
Center 55
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 20 25.250000 991.2500 0.0000
P 307 342.000000 13775.5000 13775.5000
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
70 120.500000 8717.7500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 397 487.750000 23484.5000 13775.5000
Center 57
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 38 44.750000 2193.5000 0.0000
P 47 73.500000 3810.0000 3810.0000
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 85 118.250000 6003.5000 3810.0000