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
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 6436 18246.50000 674602.2500 36.9716
Subtotal (Total Children Is Unduplicated) 6436 18246.50000 674602.2500 36.9716
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Screening, Eval, and Assessment,Class #02
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 26 26.000000 236.8600 9.1100
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 10 10.000000 93.4000 9.3400
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 27 27.000000 586.7100 21.7300
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 1 1.000000 24.4700 24.4700
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 47 78.500000 5887.5000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 21 30.000000 2250.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 11 18.500000 1387.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 24 44.500000 3337.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 60 98.000000 5439.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 365 543.500000 40762.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 158 265.500000 19912.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 192 272.000000 20400.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 719 1111.500000 61688.2500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 224 309.500000 23212.5000 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
SCREEN-T1023-SCREENING 1 1.000000 50.0000 50.0000
Subtotal (Total Children Is Unduplicated) 1034 2955.500000 190968.4000 64.6146
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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 231 678.750000 33937.5000 50.0000
HERN-T1027SC-EI HEARING SERVICES AFTER SHINE 8 11.000000 550.0000 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 34 96.000000 6516.4800 67.8800
Subtotal (Total Children Is Unduplicated) 299 930.000000 50363.3100 54.1541
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Total 22132.000000 915933.9600 41.3851
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Number of Children (Unduplicated) With at Least One Service 6562
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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
221 168.500000 6290.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 904 617.750000 22681.0000 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 889 1065.250000 41132.5000 0.0000
P 2217 2501.250000 95066.8800 94802.9900
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
386 438.750000 20281.8300 0.0000
Other 4 4.750000 175.7500 0.0000
---------------------------------------------------------
Total 3520 4042.250000 157850.2100 94802.9900
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
1 1.000000 67.8800 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 5427 5268.500000 228619.8900 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 9 16.500000 1120.5000 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
3 3.500000 233.2500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 7692 5242.500000 219462.7500 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
4 5.000000 300.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 1062 967.250000 40319.2500 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
132 90.250000 4042.2500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 1618 1124.000000 47853.6600 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
50 45.000000 2191.5000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 1724 1624.000000 63394.2500 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 1113 1044.750000 43463.5000 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 0 0.000000 0.0000 0.0000
9 16.500000 976.7600 435.7600
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 1954 1967.750000 85440.7600 40903.5100