CMS/EIP Fiscal Report Statewide
Services beginning 10/01/2013 ending 12/31/2013 Date of Report:02/18/2014 Page: 1
List order: No List
Payclass Filters:MED
Bill Flag Filter:RBPU
Eligibility Filter:All
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 6476 20862.50000 771517.7500 36.9811
Subtotal (Total Children Is Unduplicated) 6476 20862.50000 771517.7500 36.9811
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 46 75.000000 5625.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 20 24.500000 1837.5000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 10 14.000000 1050.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 33 52.000000 3900.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 51 75.500000 4190.2500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 442 652.000000 48900.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 216 325.500000 24412.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 246 350.500000 26287.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 737 1111.500000 61688.2500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 452 592.000000 44400.0000 75.0000
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 5 5.000000 253.1500 50.6300
MED-99212-OUTPATIENT VISIT, EST, 10 MINS 2 2.000000 52.9000 26.4500
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 3 3.000000 92.4500 30.8167
PSTH-97001-EVAL BY LICENSED PT, INITIAL 2 2.000000 97.0000 48.5000
SCREEN-T1023-SCREENING 2 2.000000 100.0000 50.0000
Subtotal (Total Children Is Unduplicated) 1181 3286.500000 222886.5000 67.8188
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 64 262.250000 13112.5000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 5 21.000000 1425.4800 67.8800
PHY-97110-PT SESSION BY LICENSED PT 29 125.250000 8501.9700 67.8800
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 44 172.000000 11675.3600 67.8800
SPL-92508-GROUP SPL SESSION PER CHILD 1 1.000000 13.2000 13.2000
Subtotal (Total Children Is Unduplicated) 140 581.500000 34728.5100 59.7223
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Total 24730.500000 1029132.7600 41.6139
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Number of Children (Unduplicated) With at Least One Service 6514
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Center 02
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 48 28.250000 1082.2500 0.0000
U 0 0.000000 0.0000 0.0000
B 794 526.500000 20209.2500 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
0 0.000000 0.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 842 554.750000 21291.5000 0.0000
Center 03
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 40 31.000000 1324.7500 0.0000
U 0 0.000000 0.0000 0.0000
B 1803 1245.000000 52756.3600 9.2500
P 1568 991.750000 41511.2500 41511.2550
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 3411 2267.750000 95592.3600 41520.5050
Center 04
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 33 27.500000 1853.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 1855 2331.250000 89373.7500 0.0000
P 1980 2458.250000 94828.5000 94864.2400
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 3868 4817.000000 186055.7500 94864.2400
Center 09
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 6926 6704.250000 292948.6500 55.5000
P 98 117.000000 5720.2500 5773.5000
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
0 0.000000 0.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 7024 6821.250000 298668.9000 5829.0000
Center 10
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 79 48.250000 1785.2500 0.0000
U 0 0.000000 0.0000 0.0000
B 8243 5496.750000 215247.5000 0.0000
P 406 633.000000 43679.7500 43519.7500
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 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 8728 6178.000000 260712.5000 43519.7500
Center 55
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 4 3.000000 111.0000 0.0000
P 1463 1413.750000 55998.2500 55995.2500
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
0 0.000000 0.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 1467 1416.750000 56109.2500 55995.2500
Center 57
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 33 22.500000 832.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 1710 1355.250000 55035.5000 0.0000
P 1308 1297.250000 54834.5000 54788.2500
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
0 0.000000 0.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 3051 2675.000000 110702.5000 54788.2500