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:Program Patients
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 6501 21024.00000 777493.2500 36.9812
Subtotal (Total Children Is Unduplicated) 6501 21024.00000 777493.2500 36.9812
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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 50 79.000000 5886.5000 74.5127
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 21 25.000000 1875.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 14 18.000000 1350.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 45 64.500000 4837.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 61 85.000000 4717.5000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 526 756.500000 56737.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 243 362.500000 27187.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 287 385.500000 28912.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 853 1224.000000 67932.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 529 665.500000 49912.5000 75.0000
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 6 6.000000 303.7800 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) 1416 3822.500000 255036.6900 66.7199
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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 2466 20980.50000 1048705.0000 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) 2933 26500.25000 1418875.6600 53.5420
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Total 51346.750000 2451405.6000 47.7422
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Number of Children (Unduplicated) With at Least One Service 6898
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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
1 1.500000 55.5000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 843 556.250000 21347.0000 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 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 2 1.250000 46.2500 0.0000
H 2443 8141.250000 413609.8000 297069.7200
T 0 0.000000 0.0000 0.0000
590 801.750000 49529.0200 0.0000
Other 6 9.750000 468.8300 237.5800
---------------------------------------------------------
Total 6909 13771.000000 649709.6500 392171.5400
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
1692 5167.000000 285665.8400 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 8716 11988.250000 584334.7400 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
2096 6308.750000 337680.1500 0.0000
Other 3 4.000000 281.0000 0.0000
---------------------------------------------------------
Total 10827 12490.750000 598673.6500 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
132 190.250000 12678.5000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 1599 1607.000000 68787.7500 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
1747 5939.750000 321479.8200 321329.8200
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 4798 8614.750000 432182.3200 376118.0700