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: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 6483 18307.75000 676868.5000 36.9717
Subtotal (Total Children Is Unduplicated) 6483 18307.75000 676868.5000 36.9717
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Screening, Eval, and Assessment,Class #02
AUDE-92552-PURE TONE AUDIOMETRY -AIR ONLY 1 1.000000 13.0500 13.0500
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 27 27.000000 245.9700 9.1100
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 11 11.000000 102.7400 9.3400
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 28 28.000000 608.4400 21.7300
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 2 2.000000 48.9400 24.4700
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 53 88.000000 6600.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 26 39.000000 2925.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 13 21.000000 1575.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 25 46.500000 3487.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 68 112.500000 6243.7500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 443 676.500000 50737.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 195 330.000000 24750.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 203 288.500000 21637.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 759 1181.000000 65545.5000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 253 364.000000 27300.0000 75.0000
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 101 101.000000 5113.6300 50.6300
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 18 18.000000 586.0800 32.5600
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 6 7.000000 339.5000 48.5000
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 37 37.000000 1794.5000 48.5000
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 6 6.000000 291.0000 48.5000
PSTH-97001-EVAL BY LICENSED PT, INITIAL 27 27.000000 1309.5000 48.5000
SCREEN-T1023-SCREENING 1 1.000000 50.0000 50.0000
SPCH-92506-SPEECH EVAL BY LICENSED SLP 47 48.000000 2328.0000 48.5000
Subtotal (Total Children Is Unduplicated) 1197 3461.000000 223633.1000 64.6152
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EI Services,Class #03
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 7 11.000000 275.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 2877 21134.00000 1056650.0000 49.9976
HERN-T1027SC-EI HEARING SERVICES AFTER SHINE 9 12.000000 600.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 319 1818.914200 123349.1100 67.8147
OCCT-97530HM-OT SESSION BY OT ASST 16 62.500000 3395.0000 54.3200
PHY-97110-PT SESSION BY LICENSED PT 471 2344.385600 159136.9000 67.8800
PHY-97110HM-PT SESSION BY PT ASST 33 148.500000 8066.5200 54.3200
SHIN-T1027SC-INITIAL SHINE SERVICES, INDIVIDUAL 5 6.000000 300.0000 50.0000
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 498 2666.000000 180858.7200 67.8390
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 3 6.500000 353.0800 54.3200
SPL-92508-GROUP SPL SESSION PER CHILD 3 5.250000 69.3000 13.2000
Subtotal (Total Children Is Unduplicated) 3664 28215.04980 1533053.6300 54.3346
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Total 49983.799800 2433555.2300 48.6869
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Number of Children (Unduplicated) With at Least One Service 7194
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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 683 449.250000 16391.0000 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
307 326.000000 17488.2500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 990 775.250000 33879.2500 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 313 227.250000 9754.2500 0.0000
P 1788 977.750000 39226.5000 39255.7500
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
1 1.500000 112.5000 0.0000
Other 64 64.000000 941.4400 0.0000
---------------------------------------------------------
Total 2178 1278.000000 50312.1900 39255.7500
Center 04
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 23 31.750000 1174.7500 0.0000
U 0 0.000000 0.0000 0.0000
B 925 1100.500000 42436.7500 0.0000
P 2259 2526.500000 96001.1300 95737.2400
D 1 0.500000 18.5000 0.0000
S 0 0.000000 0.0000 0.0000
H 2132 7136.000000 360621.6400 360217.6600
T 0 0.000000 0.0000 0.0000
593 823.000000 45918.9800 0.0000
Other 6 9.750000 497.2700 321.5200
---------------------------------------------------------
Total 5939 11628.000000 546669.0200 456276.4200
Center 09
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 2 2.500000 92.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 5421 5261.750000 228339.2600 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
1782 5248.000000 291618.6200 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 7208 10515.500000 520170.6300 120.2500
Center 10
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 220 120.750000 4467.7500 0.0000
U 0 0.000000 0.0000 0.0000
B 7459 5101.500000 213632.0000 0.0000
P 10 17.500000 1188.3800 1120.5000
D 0 0.000000 0.0000 0.0000
S 1 0.250000 9.2500 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
2104 5944.750000 328321.0300 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 9794 11184.750000 547618.4100 1120.5000
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 1056 960.000000 39860.0000 39860.0000
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
687 694.500000 36880.3500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 1745 1656.750000 76899.6000 39860.0000
Center 54
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 179 181.000000 9725.6600 0.0000
P 1306 852.250000 34067.2500 34067.2500
D 1 0.500000 18.5000 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
1191 1153.799800 62573.2000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 2677 2187.549800 106384.6100 34067.2500
Center 55
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 39 41.500000 1535.5000 0.0000
P 1631 1534.000000 59537.7500 59537.7500
D 0 0.000000 0.0000 0.0000
S 4 3.500000 129.5000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
2113 1906.000000 119429.2400 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 3787 3485.000000 180631.9900 59537.7500
Center 57
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 2 1.000000 37.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 1114 1045.500000 43491.2500 0.0000
P 825 897.750000 40467.7500 40467.7500
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 5 7.750000 495.7500 0.0000
T 3 9.000000 450.0000 450.0000
1556 5312.000000 286047.7800 285482.9800
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 3505 7273.000000 370989.5300 326400.7300