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:Program Patients
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 6345 19487.00000 720710.5000 36.9842
Subtotal (Total Children Is Unduplicated) 6345 19487.00000 720710.5000 36.9842
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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) 36 38.000000 346.1800 9.1100
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 19 21.000000 196.1400 9.3400
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 35 37.000000 804.0100 21.7300
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 64 105.000000 7875.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 28 39.000000 2925.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 24 39.000000 2925.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 34 56.000000 4170.7500 74.4777
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 99 154.000000 8547.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 705 1063.000000 79725.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 282 469.500000 35212.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 335 468.000000 35100.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 1199 1845.000000 102397.5000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 425 533.000000 39945.7500 74.9451
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 112 112.000000 5660.4300 50.5396
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 39 39.000000 1891.5000 48.5000
Subtotal (Total Children Is Unduplicated) 1746 5108.500000 331688.4200 64.9287
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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 2556 22051.25000 1102366.5000 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) 3296 29096.75000 1576204.0400 54.1711
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Total 53692.250000 2628602.9600 48.9568
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Number of Children (Unduplicated) With at Least One Service 6869
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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 1194 735.250000 27139.5000 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
170 312.250000 20953.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 1365 1048.000000 48111.0000 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 662 514.750000 23657.5000 0.0000
P 1749 1412.500000 63823.7500 63636.2500
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 1.500000 55.5000 0.0000
Other 100 100.000000 1474.1100 0.0000
---------------------------------------------------------
Total 2520 2030.000000 89057.1100 63636.2500
Center 04
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 4 4.250000 157.2500 0.0000
U 0 0.000000 0.0000 0.0000
B 1263 1487.250000 57071.0000 0.0000
P 2865 3263.000000 125458.3100 126459.5600
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
607 754.000000 43655.7800 0.0000
Other 6 4.250000 157.2500 0.0000
---------------------------------------------------------
Total 7211 13868.750000 649706.2700 423120.7100
Center 09
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 82 77.750000 2876.7500 0.0000
U 0 0.000000 0.0000 0.0000
B 1330 1274.250000 63119.6700 46.2500
P 4992 4908.250000 212335.1500 212204.3400
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
1816 5552.500000 309536.3100 0.0000
Other 7 7.750000 362.7500 307.2500
---------------------------------------------------------
Total 8228 11821.000000 588249.1300 212576.3400
Center 10
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 478 333.000000 12548.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 6148 3936.750000 150540.0000 0.0000
P 703 1151.000000 76610.0000 75740.0000
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
2461 7042.250000 387042.7400 0.0000
Other 2 2.500000 148.5000 0.0000
---------------------------------------------------------
Total 9792 12465.500000 626889.2400 75740.0000
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 2146 2085.250000 82223.0000 82252.2500
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
2272 2106.750000 135128.8000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 4432 4203.250000 217825.0500 82252.2500
Center 57
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 19 15.000000 555.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 1421 1167.250000 43994.8900 0.0000
P 1292 1412.250000 64748.7500 64747.8500
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
1700 5661.250000 299466.5200 298687.4400
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 4432 8255.750000 408765.1600 363435.2900