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
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 6069 19454.00000 719403.2500 36.9797
Subtotal (Total Children Is Unduplicated) 6069 19454.00000 719403.2500 36.9797
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Screening, Eval, and Assessment,Class #02
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 21 21.000000 199.5000 9.5000
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 8 8.000000 71.9300 8.9913
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 21 21.000000 449.7600 21.4171
AUDE-92585-AUD EVOKED RESPONSE (DIAG) 1 1.000000 56.9400 56.9400
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 39 65.500000 4874.0000 74.4122
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 18 20.500000 1537.5000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 13 17.500000 1312.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 42 61.000000 4575.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 49 67.000000 3718.5000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 397 570.000000 42750.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 177 267.000000 20025.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 229 316.500000 23737.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 636 922.500000 51198.7500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 387 501.000000 37575.0000 75.0000
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 4 4.000000 202.5200 50.6300
MED-99212-OUTPATIENT VISIT, EST, 10 MINS 3 3.000000 79.3500 26.4500
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 11 11.000000 352.9300 32.0845
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 1 1.000000 48.5000 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 13 13.000000 630.5000 48.5000
PSTH-97001-EVAL BY LICENSED PT, INITIAL 26 26.000000 1261.0000 48.5000
SCREEN-T1023-SCREENING 2 2.000000 100.0000 50.0000
SPCH-92506-SPEECH EVAL BY LICENSED SLP 24 24.000000 1164.0000 48.5000
Subtotal (Total Children Is Unduplicated) 1095 2963.500000 196890.6800 66.4386
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EI Services,Class #03
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 1 5.000000 125.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 2465 20976.50000 1048505.0000 49.9847
OCCT-97530-OT SESSION BY LICENSED OT 243 1617.750000 109812.8700 67.8800
OCCT-97530HM-OT SESSION BY OT ASST 14 81.000000 4399.9200 54.3200
PHY-97110-PT SESSION BY LICENSED PT 296 1676.250000 113783.8500 67.8800
PHY-97110HM-PT SESSION BY PT ASST 35 196.250000 10660.3000 54.3200
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 320 1907.000000 129447.1600 67.8800
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 7 35.500000 1928.3600 54.3200
SPL-92508-GROUP SPL SESSION PER CHILD 1 1.000000 13.2000 13.2000
Subtotal (Total Children Is Unduplicated) 2932 26496.25000 1418675.6600 53.5425
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Total 48913.750000 2334969.5900 47.7365
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Number of Children (Unduplicated) With at Least One Service 6456
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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 787 522.750000 20070.5000 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
1 1.500000 55.5000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 836 552.500000 21208.2500 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 51 51.000000 778.1300 0.0000
---------------------------------------------------------
Total 3462 2318.750000 96370.4900 41520.5050
Center 04
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 22 20.500000 1328.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 1679 2059.000000 78403.7500 0.0000
P 1804 2212.000000 84590.2400 84625.9800
D 0 0.000000 0.0000 0.0000
S 2 1.250000 46.2500 0.0000
H 2443 8141.250000 413609.8000 297069.7200
T 0 0.000000 0.0000 0.0000
514 733.000000 45431.5200 0.0000
Other 6 9.750000 468.8300 237.5800
---------------------------------------------------------
Total 6470 13176.750000 623878.8900 381933.2800
Center 09
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 6449 5930.500000 252256.4000 55.5000
P 92 106.750000 5066.2500 5119.5000
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
1692 5167.000000 285665.8400 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 8233 11204.250000 542988.4900 5175.0000
Center 10
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 73 42.000000 1554.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 7538 4779.500000 185113.5000 0.0000
P 296 470.500000 32711.0000 32551.0000
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
2096 6308.750000 337680.1500 0.0000
Other 3 4.000000 281.0000 0.0000
---------------------------------------------------------
Total 10006 11604.750000 557339.6500 32551.0000
Center 55
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 4 3.000000 111.0000 0.0000
P 1462 1413.250000 55979.7500 55976.7500
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
132 190.250000 12678.5000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 1598 1606.500000 68769.2500 55976.7500
Center 57
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 31 21.000000 777.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 1655 1295.750000 52108.2500 0.0000
P 1231 1197.750000 50249.5000 50203.2500
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
1745 5935.750000 321279.8200 321129.8200
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 4662 8450.250000 424414.5700 371333.0700