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
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 5690 17407.00000 643767.0000 36.9832
Subtotal (Total Children Is Unduplicated) 5690 17407.00000 643767.0000 36.9832
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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 47 76.000000 5700.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 14 17.500000 1312.5000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 16 26.000000 1950.0000 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 71 105.500000 5855.2500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 364 506.000000 37950.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 142 240.000000 18000.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 207 294.500000 22087.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 792 1188.000000 65934.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 313 384.000000 28770.7500 74.9238
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
PSTH-97001-EVAL BY LICENSED PT, INITIAL 1 1.000000 48.5000 48.5000
SPCH-92506-SPEECH EVAL BY LICENSED SLP 1 1.000000 48.5000 48.5000
Subtotal (Total Children Is Unduplicated) 1109 3082.000000 197828.6300 64.1884
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 39 190.000000 9500.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 5 21.000000 1425.4800 67.8800
PHY-97110-PT SESSION BY LICENSED PT 28 138.000000 9367.4400 67.8800
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 33 161.500000 10962.6200 67.8800
Subtotal (Total Children Is Unduplicated) 102 510.500000 31255.5400 61.2253
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Total 20999.500000 872851.1700 41.5653
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Number of Children (Unduplicated) With at Least One Service 5733
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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
29 42.750000 2339.5000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 1104 685.500000 26056.5000 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 1197 1406.500000 53743.7500 0.0000
P 2610 2945.750000 112692.3700 113486.2800
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
366 388.750000 19977.8000 0.0000
Other 6 4.250000 157.2500 0.0000
---------------------------------------------------------
Total 4181 4747.250000 186645.1700 113486.2800
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
1 1.250000 46.2500 0.0000
Other 5 4.250000 157.2500 101.7500
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Total 5880 5428.500000 235260.8200 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 454 749.000000 50412.7500 50412.7500
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 2 2.500000 148.5000 0.0000
---------------------------------------------------------
Total 6459 4426.000000 190369.2500 50412.7500
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
1 1.000000 37.0000 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 1870 1773.250000 69555.5000 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
12 11.500000 779.0800 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 2588 2421.000000 101488.4700 58888.8500