CMS/EIP Fiscal Report Statewide
Services beginning 04/01/2013 ending 06/30/2013 Date of Report:08/19/2013 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 5711 17446.25000 645219.2500 36.9833
Subtotal (Total Children Is Unduplicated) 5711 17446.25000 645219.2500 36.9833
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Screening, Eval, and Assessment,Class #02
AUDE-92553-PURE TONE AUDIOMETRY AIR & BONE 1 1.000000 16.7800 16.7800
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 33 33.000000 300.6300 9.1100
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 16 16.000000 149.4400 9.3400
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 32 32.000000 695.3600 21.7300
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 52 84.000000 6300.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 16 20.500000 1537.5000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 17 27.500000 2062.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 33 54.500000 4058.2500 74.4633
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 74 110.500000 6132.7500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 500 740.500000 55537.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 179 307.000000 23025.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 220 314.000000 23550.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 834 1266.500000 70290.7500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 325 407.000000 30495.7500 74.9281
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 83 83.000000 4202.2900 50.6300
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 23 23.000000 748.8800 32.5600
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 12 12.000000 582.0000 48.5000
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 20 20.000000 970.0000 48.5000
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 11 11.000000 533.5000 48.5000
PSTH-97001-EVAL BY LICENSED PT, INITIAL 23 23.000000 1115.5000 48.5000
SPCH-92506-SPEECH EVAL BY LICENSED SLP 38 38.000000 1843.0000 48.5000
Subtotal (Total Children Is Unduplicated) 1261 3624.000000 234147.3800 64.6102
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EI Services,Class #03
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 1 1.000000 25.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 2555 22050.25000 1102316.5000 49.9911
OCCT-97530-OT SESSION BY LICENSED OT 341 1781.000000 120894.2800 67.8800
OCCT-97530HM-OT SESSION BY OT ASST 29 113.750000 6178.9000 54.3200
PHY-97110-PT SESSION BY LICENSED PT 464 2249.750000 152713.0300 67.8800
PHY-97110HM-PT SESSION BY PT ASST 36 169.750000 9220.8200 54.3200
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 502 2706.250000 183666.3100 67.8675
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 7 20.000000 1086.4000 54.3200
SPL-92508-GROUP SPL SESSION PER CHILD 2 4.000000 52.8000 13.2000
Subtotal (Total Children Is Unduplicated) 3295 29095.75000 1576154.0400 54.1713
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Total 50166.000000 2455520.6700 48.9479
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Number of Children (Unduplicated) With at Least One Service 6199
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Center 02
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 1 0.500000 18.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 1074 642.250000 23698.5000 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
135 248.250000 16582.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 1210 891.000000 40299.0000 0.0000
Center 03
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 4 1.250000 46.2500 0.0000
U 0 0.000000 0.0000 0.0000
B 573 395.500000 17305.7500 0.0000
P 1449 1037.000000 44878.0000 44690.5000
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
5 1.500000 55.5000 0.0000
Other 83 82.750000 1189.9600 0.0000
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Total 2114 1518.000000 63475.4600 44690.5000
Center 04
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 2 2.000000 74.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 1201 1411.500000 53928.7500 0.0000
P 2651 2986.000000 114259.6200 115043.5300
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 2466 8356.000000 423206.6800 296661.1500
T 0 0.000000 0.0000 0.0000
533 691.750000 40095.5800 0.0000
Other 6 4.250000 157.2500 0.0000
---------------------------------------------------------
Total 6859 13451.500000 631721.8800 411704.6800
Center 09
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 73 65.250000 2414.2500 0.0000
U 0 0.000000 0.0000 0.0000
B 1246 1136.750000 55489.4200 46.2500
P 4554 4220.500000 177135.1500 177059.8400
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 1 0.500000 18.5000 18.5000
T 0 0.000000 0.0000 0.0000
1815 5551.750000 309508.5600 0.0000
Other 5 4.250000 157.2500 101.7500
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Total 7694 10979.000000 544723.1300 177226.3400
Center 10
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 447 299.750000 11317.7500 0.0000
U 0 0.000000 0.0000 0.0000
B 5556 3374.750000 128490.2500 0.0000
P 463 771.000000 51512.7500 50642.7500
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
2460 7040.250000 386968.7400 0.0000
Other 2 2.500000 148.5000 0.0000
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Total 8928 11488.250000 578437.9900 50642.7500
Center 55
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 14 11.250000 473.2500 0.0000
P 1855 1761.000000 69045.2500 69074.5000
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
2202 1996.250000 127218.8000 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 4071 3768.500000 196737.3000 69074.5000
Center 57
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 19 15.000000 555.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 1350 1096.750000 41264.6400 0.0000
P 1207 1297.750000 58889.7500 58888.8500
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
1699 5660.250000 299416.5200 298637.4400
Other 0 0.000000 0.0000 0.0000
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Total 4275 8069.750000 400125.9100 357526.2900