CMS/EIP Fiscal Report Statewide
Services beginning 01/01/2013 ending 03/31/2013 Date of Report:05/17/2013 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 549 1832.250000 67765.5000 36.9849
Subtotal (Total Children Is Unduplicated) 549 1832.250000 67765.5000 36.9849
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Screening, Eval, and Assessment,Class #02
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 6 6.000000 54.6600 9.1100
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 4 4.000000 37.3600 9.3400
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 7 7.000000 152.1100 21.7300
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 7 11.500000 862.5000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 6 8.500000 637.5000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 2 2.000000 150.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 3 6.000000 450.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 13 19.000000 1054.5000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 188 291.000000 21825.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 95 150.500000 11287.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 68 81.000000 6075.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 306 464.000000 25752.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 74 99.500000 7462.5000 75.0000
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 26 26.000000 1316.3800 50.6300
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 1 1.000000 32.5600 32.5600
PSTH-97001-EVAL BY LICENSED PT, INITIAL 1 1.000000 48.5000 48.5000
Subtotal (Total Children Is Unduplicated) 398 1178.000000 77198.0700 65.5332
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 2 20.000000 1000.0000 50.0000
Subtotal (Total Children Is Unduplicated) 2 20.000000 1000.0000 50.0000
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Total 3030.250000 145963.5700 48.1688
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Number of Children (Unduplicated) With at Least One Service 581
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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 115 102.500000 3764.7500 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
31 52.500000 3557.2500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 146 155.000000 7322.0000 0.0000
Center 03
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 4 1.750000 64.7500 0.0000
U 0 0.000000 0.0000 0.0000
B 73 86.000000 4142.5000 0.0000
P 168 137.000000 6139.0000 6139.0000
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
1 2.000000 111.0000 0.0000
Other 18 17.750000 271.8800 0.0000
---------------------------------------------------------
Total 264 244.500000 10729.1300 6139.0000
Center 04
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 2 1.750000 64.7500 0.0000
U 0 0.000000 0.0000 0.0000
B 97 150.250000 5850.0000 0.0000
P 111 162.250000 6822.2300 6814.4400
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 3 13.000000 650.0000 450.0000
T 0 0.000000 0.0000 0.0000
68 54.000000 3102.9600 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 281 381.250000 16489.9400 7264.4400
Center 09
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 384 626.000000 32182.5000 0.0000
P 35 58.500000 3338.2500 3338.2500
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
5 10.000000 575.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 424 694.500000 36095.7500 3338.2500
Center 10
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 21 20.500000 758.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 219 194.500000 7196.5000 0.0000
P 626 713.500000 37718.7500 37718.7500
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
4 8.250000 305.2500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 870 936.750000 45979.0000 37718.7500
Center 55
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 0 0.000000 0.0000 0.0000
P 343 417.500000 17100.5000 17100.5000
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
58 91.500000 6680.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 401 509.000000 23780.5000 17100.5000
Center 57
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 5 7.250000 268.2500 0.0000
U 0 0.000000 0.0000 0.0000
B 30 44.250000 1967.0000 0.0000
P 39 57.750000 3332.0000 3332.0000
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 74 109.250000 5567.2500 3332.0000