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
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 6010 19351.00000 715592.2500 36.9796
Subtotal (Total Children Is Unduplicated) 6010 19351.00000 715592.2500 36.9796
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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 37 62.500000 4687.5000 75.0000
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 12 16.000000 1200.0000 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 340 483.500000 36262.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 158 237.500000 17812.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 219 301.500000 22612.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 619 897.000000 49783.5000 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
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) 1022 2720.500000 181374.4300 66.6695
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 62 256.250000 12812.5000 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) 138 575.500000 34428.5100 59.8236
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Total 22647.000000 931395.1900 41.1266
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Number of Children (Unduplicated) With at Least One Service 6041
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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 1584 1988.000000 75776.7500 0.0000
P 1753 2177.250000 83265.4900 83301.2300
D 0 0.000000 0.0000 0.0000
S 2 1.250000 46.2500 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
288 285.500000 15645.5600 0.0000
Other 5 6.250000 231.2500 0.0000
---------------------------------------------------------
Total 3654 4478.750000 176293.8000 83301.2300
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
1 1.000000 50.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 6542 6038.250000 257372.6500 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 295 466.500000 32511.0000 32511.0000
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
6 4.750000 175.7500 0.0000
Other 3 4.000000 281.0000 0.0000
---------------------------------------------------------
Total 7915 5296.750000 219635.2500 32511.0000
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
26 29.250000 1139.2500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 1492 1445.500000 57230.0000 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
2 2.000000 150.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 2919 2516.500000 103284.7500 50203.2500