CMS/EIP Fiscal Report Statewide
Services beginning 01/01/2014 ending 03/31/2014 Date of Report:06/03/2014 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 3349 8144.750000 301355.7500 37.0000
Subtotal (Total Children Is Unduplicated) 3349 8144.750000 301355.7500 37.0000
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Screening, Eval, and Assessment,Class #02
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 9 9.000000 90.1800 10.0200
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 5 6.000000 50.4600 8.4100
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 9 9.000000 189.0000 21.0000
AUDE-92585-AUD EVOKED RESPONSE (DIAG) 1 1.000000 62.6300 62.6300
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 12 15.000000 1125.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 4 4.000000 300.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 2 2.500000 187.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 18 24.000000 1800.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 24 27.000000 1498.5000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 210 275.500000 20662.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 50 71.500000 5362.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 112 132.500000 9937.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 345 436.000000 24198.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 200 248.000000 18600.0000 75.0000
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 3 3.000000 151.8900 50.6300
MED-99212-OUTPATIENT VISIT, EST, 10 MINS 1 1.000000 18.1700 18.1700
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 1 1.000000 32.5600 32.5600
MED-99214-OUTPATIENT VISIT, EST, 25 MINS 1 1.000000 48.2700 48.2700
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 9 9.000000 436.5000 48.5000
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 20 26.000000 1261.0000 48.5000
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 7 7.000000 339.5000 48.5000
PSTH-97001-EVAL BY LICENSED PT, INITIAL 27 27.000000 1309.5000 48.5000
SPCH-92506-SPEECH EVAL BY LICENSED SLP 36 36.000000 1746.0000 48.5000
Subtotal (Total Children Is Unduplicated) 561 1372.000000 89407.1600 65.1656
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 2019 10606.75000 530337.5000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 182 708.500000 48092.9800 67.8800
OCCT-97530HM-OT SESSION BY OT ASST 10 46.750000 2539.4600 54.3200
PHY-97110-PT SESSION BY LICENSED PT 222 709.500000 48160.8600 67.8800
PHY-97110HM-PT SESSION BY PT ASST 42 162.500000 8827.0000 54.3200
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 233 813.750000 55237.3500 67.8800
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 10 33.500000 1819.7200 54.3200
Subtotal (Total Children Is Unduplicated) 2390 13081.25000 695014.8700 53.1306
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Total 22598.000000 1085777.7800 48.0475
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Number of Children (Unduplicated) With at Least One Service 4103
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Center 03
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 0 0.000000 0.0000 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 25 25.000000 392.2700 0.0000
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Total 25 25.000000 392.2700 0.0000
Center 04
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 77 89.250000 3867.7500 0.0000
P 2466 3050.000000 116932.6300 116984.4500
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 1592 5185.000000 264380.6000 262183.1600
T 0 0.000000 0.0000 0.0000
438 529.500000 31675.5100 0.0000
Other 2 2.250000 83.2500 0.0000
---------------------------------------------------------
Total 4575 8856.000000 416939.7400 379167.6100
Center 09
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 2073 1998.750000 87876.9800 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
570 1796.250000 99058.0500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 2643 3795.000000 186935.0300 0.0000
Center 10
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 2811 2000.000000 83733.0000 0.0000
P 0 0.000000 0.0000 0.0000
D 0 0.000000 0.0000 0.0000
S 5 4.250000 157.2500 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
688 2110.250000 113417.7200 0.0000
Other 1 0.250000 9.2500 0.0000
---------------------------------------------------------
Total 3505 4114.750000 197317.2200 0.0000
Center 55
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 0 0.000000 0.0000 0.0000
P 22 20.500000 815.5000 815.5000
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 22 20.500000 815.5000 815.5000
Center 57
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 44 46.500000 2859.7500 0.0000
P 2397 2076.750000 84811.7500 84811.7500
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
1104 3663.500000 195706.5200 195310.6900
Other 0 0.000000 0.0000 0.0000
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Total 3545 5786.750000 283378.0200 280122.4400