CMS/EIP Fiscal Report Statewide
Services beginning 04/01/2013 ending 06/30/2013 Date of Report:08/18/2013 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 607 1977.000000 73132.5000 36.9917
Subtotal (Total Children Is Unduplicated) 607 1977.000000 73132.5000 36.9917
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Screening, Eval, and Assessment,Class #02
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 3 5.000000 45.5500 9.1100
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 3 5.000000 46.7000 9.3400
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 3 5.000000 108.6500 21.7300
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 12 21.000000 1575.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 11 18.000000 1350.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 7 11.500000 862.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 1 1.500000 112.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 25 43.500000 2414.2500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 204 321.000000 24075.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 103 162.500000 12187.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 115 154.000000 11550.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 365 578.500000 32106.7500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 99 124.500000 9337.5000 75.0000
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 29 29.000000 1458.1400 50.2807
SPCH-92506-SPEECH EVAL BY LICENSED SLP 1 1.000000 48.5000 48.5000
Subtotal (Total Children Is Unduplicated) 483 1481.000000 97278.5400 65.6844
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 1 1.000000 50.0000 50.0000
Subtotal (Total Children Is Unduplicated) 1 1.000000 50.0000 50.0000
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Total 3459.000000 170461.0400 49.2804
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Number of Children (Unduplicated) With at Least One Service 643
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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 120 93.000000 3441.0000 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
35 64.000000 4371.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 155 157.000000 7812.0000 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 89 119.250000 6351.7500 0.0000
P 300 375.500000 18945.7500 18945.7500
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 17 17.250000 284.1500 0.0000
---------------------------------------------------------
Total 406 512.000000 25581.6500 18945.7500
Center 04
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 2 2.250000 83.2500 0.0000
U 0 0.000000 0.0000 0.0000
B 53 69.250000 2901.7500 0.0000
P 151 228.000000 9385.6900 9603.0300
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
71 60.750000 3485.7000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 277 360.250000 15856.3900 9603.0300
Center 09
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 9 12.500000 462.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 84 137.500000 7630.2500 0.0000
P 438 687.750000 35200.0000 35144.5000
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
1 0.750000 27.7500 0.0000
Other 2 3.500000 205.5000 205.5000
---------------------------------------------------------
Total 534 842.000000 43526.0000 35350.0000
Center 10
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 31 33.250000 1230.2500 0.0000
U 0 0.000000 0.0000 0.0000
B 592 562.000000 22049.7500 0.0000
P 240 380.000000 25097.2500 25097.2500
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 2.000000 74.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 864 977.250000 48451.2500 25097.2500
Center 55
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 0 0.000000 0.0000 0.0000
P 284 315.500000 12797.0000 12797.0000
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
69 109.000000 7797.5000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 353 424.500000 20594.5000 12797.0000
Center 57
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 71 70.500000 2730.2500 0.0000
P 85 114.500000 5859.0000 5859.0000
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 1.000000 50.0000 50.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 157 186.000000 8639.2500 5909.0000