CMS/EIP Fiscal Report Statewide
Services beginning 07/01/2008 ending 09/30/2008 Date of Report:11/18/2008 Page: 1
Agency Filter:EXT
Payclass Filters:MED
Eligibility Filter:Part C (excluding not eligible)
List order: No List
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 119 228.75 8463.75 37.00
Subtotal (Total Children Is Unduplicated) 119 228.75 8463.75 37.00
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Screening, Eval, and Assessment,Class #02
AUD-92626-EVAL OF AUD REHAB STATUS 1 1.00 36.07 36.07
AUDE-92552-PURE TONE AUDIOMETRY -AIR ONLY 2 2.00 21.24 10.62
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 11 11.00 97.13 8.83
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 13 13.00 139.98 10.77
AUDE-92568-ACOUSTIC REFLEX TESTING (MEMR) 1 1.00 8.44 8.44
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 11 11.00 239.69 21.79
AUDE-92585-AUD EVOKED RESPONSE (DIAG) 1 1.00 54.38 54.38
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 1 1.00 28.28 28.28
AUDE-92588-OTOACOUSTIC EMISSIONS (COMP) 4 4.00 127.24 31.81
AUDE-V5090-DISPENSING FEE PER HEARING AID 1 1.00 119.60 119.60
BEHV-H0031HO-COMP BEHAVIORAL HEALTH ASSESSMENT 1 1.00 50.00 50.00
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 11 14.00 1050.00 75.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 1.00 75.00 75.00
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 6 6.50 487.50 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 4 4.50 337.50 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 15 23.00 1264.75 54.99
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 82 108.75 7967.50 73.26
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 36 53.00 3975.00 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 35 44.00 3225.00 73.30
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 98 156.00 8599.50 55.13
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 51 66.00 4912.50 74.43
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 35 35.00 1697.50 48.50
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 47 49.00 2376.50 48.50
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 46 57.00 2764.50 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 45 45.00 2182.50 48.50
SPCH-92506-SPEECH EVAL BY LICENSED SLP 115 118.00 5723.00 48.50
Subtotal (Total Children Is Unduplicated) 483 827.75 47560.30 57.46
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 4 15.00 1490.75 99.38
COUN-H2019HR-INDIVIDUAL/FAMILY THERAPY 2 13.00 954.46 73.42
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 8 38.00 945.00 24.87
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 1658 11432.8 571108.13 49.95
HERN-T1027SC-EI HEARING SERVICES AFTER SHINE 1 6.00 300.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 563 2631.25 178555.01 67.86
OCCT-97530HM-OT SESSION BY OT ASST 64 245.75 13349.14 54.32
PHY-97110-PT SESSION BY LICENSED PT 779 3459.75 234763.98 67.86
PHY-97110HM-PT SESSION BY PT ASST 40 241.75 13078.54 54.10
SENS-V5264-EARMOLD 1 2.00 37.44 18.72
SHIN-T1027SC-INITIAL SHINE SERVICES, INDIVIDUAL 1 1.00 50.00 50.00
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 994 4486.50 304479.01 67.87
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 17 45.50 2471.56 54.32
SPL-92508-GROUP SPL SESSION PER CHILD 12 28.50 376.20 13.20
Subtotal (Total Children Is Unduplicated) 2988 22646.8 1321959.22 58.37
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Total 23703.25 1377983.27 58.13
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Number of Children (Unduplicated) With at Least One Service 3266
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Center 01
Flag Claims Units Chgs Paid
-------------------------------------------------
R 0 0.00 0.00 0.00
U 0 0.00 0.00 0.00
B 0 0.00 0.00 0.00
P 0 0.00 0.00 0.00
D 0 0.00 0.00 0.00
S 0 0.00 0.00 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
555 1545.25 94923.38 0.00
Other 152 154.50 9905.65 0.00
-------------------------------------------------
Total 707 1699.75 104829.03 0.00
Center 02
Flag Claims Units Chgs Paid
-------------------------------------------------
R 0 0.00 0.00 0.00
U 0 0.00 0.00 0.00
B 0 0.00 0.00 0.00
P 0 0.00 0.00 0.00
D 0 0.00 0.00 0.00
S 0 0.00 0.00 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
42 1614.25 99345.38 0.00
Other 0 154.50 9905.65 0.00
-------------------------------------------------
Total 42 1768.75 109251.03 0.00
Center 04
Flag Claims Units Chgs Paid
-------------------------------------------------
R 0 0.00 0.00 0.00
U 0 0.00 0.00 0.00
B 265 223.25 8260.25 0.00
P 4 12.00 634.26 634.26
D 4 5.50 283.94 283.94
S 0 0.00 0.00 0.00
H 940 3141.50 159075.90 159543.60
T 0 0.00 0.00 0.00
201 1976.25 122793.90 0.00
Other 0 154.50 9905.65 0.00
-------------------------------------------------
Total 1414 5513.00 300953.90 160461.80
Center 05
Flag Claims Units Chgs Paid
-------------------------------------------------
R 0 0.00 0.00 0.00
U 0 0.00 0.00 0.00
B 0 223.25 8260.25 0.00
P 0 12.00 634.26 634.26
D 0 5.50 283.94 283.94
S 0 0.00 0.00 0.00
H 0 3141.50 159075.90 159543.60
T 0 0.00 0.00 0.00
1675 3048.75 189952.43 0.00
Other 0 154.50 9905.65 0.00
-------------------------------------------------
Total 1675 6585.50 368112.43 160461.80
Center 06
Flag Claims Units Chgs Paid
-------------------------------------------------
R 0 0.00 0.00 0.00
U 0 0.00 0.00 0.00
B 0 223.25 8260.25 0.00
P 0 12.00 634.26 634.26
D 0 5.50 283.94 283.94
S 0 0.00 0.00 0.00
H 0 3141.50 159075.90 159543.60
T 0 0.00 0.00 0.00
2557 5153.25 322461.75 0.00
Other 0 154.50 9905.65 0.00
-------------------------------------------------
Total 2557 8690.00 500621.75 160461.80
Center 07
Flag Claims Units Chgs Paid
-------------------------------------------------
R 0 0.00 0.00 0.00
U 0 0.00 0.00 0.00
B 0 223.25 8260.25 0.00
P 0 12.00 634.26 634.26
D 0 5.50 283.94 283.94
S 0 0.00 0.00 0.00
H 0 3141.50 159075.90 159543.60
T 0 0.00 0.00 0.00
577 6593.25 398104.63 0.00
Other 0 154.50 9905.65 0.00
-------------------------------------------------
Total 577 10130.00 576264.63 160461.80
Center 09
Flag Claims Units Chgs Paid
-------------------------------------------------
R 1 1.00 75.00 0.00
U 0 0.00 0.00 0.00
B 0 223.25 8260.25 0.00
P 1 14.00 770.02 770.02
D 0 5.50 283.94 283.94
S 0 0.00 0.00 0.00
H 0 3141.50 159075.90 159543.60
T 0 0.00 0.00 0.00
761 8617.00 526299.85 0.00
Other 0 154.50 9905.65 0.00
-------------------------------------------------
Total 763 12156.75 704670.61 160597.56
Center 10
Flag Claims Units Chgs Paid
-------------------------------------------------
R 0 1.00 75.00 0.00
U 0 0.00 0.00 0.00
B 0 223.25 8260.25 0.00
P 1 15.00 795.02 820.02
D 0 5.50 283.94 283.94
S 0 0.00 0.00 0.00
H 0 3141.50 159075.90 159543.60
T 0 0.00 0.00 0.00
1080 10624.25 650602.85 0.00
Other 0 154.50 9905.65 0.00
-------------------------------------------------
Total 1081 14165.00 828998.61 160647.56
Center 51
Flag Claims Units Chgs Paid
-------------------------------------------------
R 0 1.00 75.00 0.00
U 0 0.00 0.00 0.00
B 0 223.25 8260.25 0.00
P 2 28.00 1664.75 1621.87
D 0 5.50 283.94 283.94
S 0 0.00 0.00 0.00
H 0 3141.50 159075.90 159543.60
T 0 0.00 0.00 0.00
802 12612.75 769468.56 0.00
Other 0 154.50 9905.65 0.00
-------------------------------------------------
Total 804 16166.50 948734.05 161449.41
Center 52
Flag Claims Units Chgs Paid
-------------------------------------------------
R 0 1.00 75.00 0.00
U 0 0.00 0.00 0.00
B 0 223.25 8260.25 0.00
P 0 28.00 1664.75 1621.87
D 0 5.50 283.94 283.94
S 0 0.00 0.00 0.00
H 0 3141.50 159075.90 159543.60
T 0 0.00 0.00 0.00
524 13872.50 851569.69 0.00
Other 0 154.50 9905.65 0.00
-------------------------------------------------
Total 524 17426.25 1030835.18 161449.41
Center 53
Flag Claims Units Chgs Paid
-------------------------------------------------
R 0 1.00 75.00 0.00
U 0 0.00 0.00 0.00
B 0 223.25 8260.25 0.00
P 0 28.00 1664.75 1621.87
D 0 5.50 283.94 283.94
S 0 0.00 0.00 0.00
H 2 3143.50 159175.90 159643.60
T 0 0.00 0.00 0.00
1327 15123.25 916789.63 0.00
Other 0 154.50 9905.65 0.00
-------------------------------------------------
Total 1329 18679.00 1096155.12 161549.41
Center 54
Flag Claims Units Chgs Paid
-------------------------------------------------
R 0 1.00 75.00 0.00
U 0 0.00 0.00 0.00
B 0 223.25 8260.25 0.00
P 0 28.00 1664.75 1621.87
D 0 5.50 283.94 283.94
S 0 0.00 0.00 0.00
H 0 3143.50 159175.90 159643.60
T 0 0.00 0.00 0.00
684 16834.50 1014697.72 0.00
Other 0 154.50 9905.65 0.00
-------------------------------------------------
Total 684 20390.25 1194063.21 161549.41
Center 55
Flag Claims Units Chgs Paid
-------------------------------------------------
R 0 1.00 75.00 0.00
U 0 0.00 0.00 0.00
B 0 223.25 8260.25 0.00
P 0 28.00 1664.75 1621.87
D 0 5.50 283.94 283.94
S 0 0.00 0.00 0.00
H 0 3143.50 159175.90 159643.60
T 0 0.00 0.00 0.00
1052 17673.00 1069367.56 0.00
Other 0 154.50 9905.65 0.00
-------------------------------------------------
Total 1052 21228.75 1248733.05 161549.41
Center 57
Flag Claims Units Chgs Paid
-------------------------------------------------
R 0 1.00 75.00 0.00
U 0 0.00 0.00 0.00
B 0 223.25 8260.25 0.00
P 0 28.00 1664.75 1621.87
D 0 5.50 283.94 283.94
S 8 27.00 1350.00 1350.00
H 0 3143.50 159175.90 159643.60
T 21 68.00 3400.00 3400.00
842 20052.50 1193867.78 106467.39
Other 0 154.50 9905.65 0.00
-------------------------------------------------
Total 871 23703.25 1377983.27 272766.80