CMS/EIP Fiscal Report Statewide
Services beginning 10/01/2008 ending 12/31/2008 Date of Report:02/17/2009 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 104 199.25 7372.25 37.00
Subtotal (Total Children Is Unduplicated) 104 199.25 7372.25 37.00
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Screening, Eval, and Assessment,Class #02
AUDE-92552-PURE TONE AUDIOMETRY -AIR ONLY 6 6.00 63.72 10.62
AUDE-92553-PURE TONE AUDIOMETRY AIR & BONE 1 1.00 16.30 16.30
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 13 13.00 114.79 8.83
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 19 19.00 205.20 10.80
AUDE-92568-ACOUSTIC REFLEX TESTING (MEMR) 7 7.00 59.08 8.44
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 15 15.00 326.85 21.79
AUDE-92585-AUD EVOKED RESPONSE (DIAG) 1 1.00 54.38 54.38
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 4 4.00 113.12 28.28
AUDE-92588-OTOACOUSTIC EMISSIONS (COMP) 8 8.00 254.48 31.81
BEHV-H0031HO-COMP BEHAVIORAL HEALTH ASSESSMENT 1 1.00 50.00 50.00
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 5 6.00 450.00 75.00
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 4 5.50 412.50 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 3 4.00 300.00 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 18 23.50 1304.25 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 104 143.00 10621.00 74.27
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 28 39.50 2962.50 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 54 91.00 6761.00 74.30
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 117 194.50 10678.75 54.90
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 81 112.00 8326.50 74.34
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 24 24.00 1164.00 48.50
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 41 43.00 2085.50 48.50
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 36 36.00 1746.00 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 41 41.00 1988.50 48.50
SPCH-92506-SPEECH EVAL BY LICENSED SLP 95 95.00 4607.50 48.50
Subtotal (Total Children Is Unduplicated) 509 933.00 54665.92 58.59
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EI Services,Class #03
COUN-H2019HR-INDIVIDUAL/FAMILY THERAPY 3 13.00 931.04 71.62
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 7 36.00 900.00 25.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 1687 11456.0 572800.00 50.00
HERN-T1027SC-EI HEARING SERVICES AFTER SHINE 1 9.00 450.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 483 2386.00 161756.10 67.79
OCCT-97530HM-OT SESSION BY OT ASST 39 140.00 7604.80 54.32
PHY-97110-PT SESSION BY LICENSED PT 647 3201.75 216935.78 67.76
PHY-97110HM-PT SESSION BY PT ASST 45 220.25 11963.94 54.32
SHIN-T1027SC-INITIAL SHINE SERVICES, INDIVIDUAL 1 2.50 125.00 50.00
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 917 4504.96 305217.94 67.75
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 12 29.50 1602.44 54.32
SPL-92508-GROUP SPL SESSION PER CHILD 6 13.00 171.60 13.20
Subtotal (Total Children Is Unduplicated) 2886 22012.0 1280458.64 58.17
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Total 23144.21 1342496.81 58.01
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Number of Children (Unduplicated) With at Least One Service 3218
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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
499 1264.00 76854.07 0.00
Other 51 44.50 2859.66 0.00
-------------------------------------------------
Total 550 1308.50 79713.73 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
65 1363.00 83352.07 0.00
Other 0 44.50 2859.66 0.00
-------------------------------------------------
Total 65 1407.50 86211.73 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 256 188.50 6974.50 0.00
P 3 3.00 111.00 111.00
D 0 0.00 0.00 0.00
S 0 0.00 0.00 0.00
H 721 2359.00 119763.62 119488.42
T 0 0.00 0.00 0.00
135 1741.00 108588.45 0.00
Other 0 44.50 2859.66 0.00
-------------------------------------------------
Total 1115 4336.00 238297.23 119599.42
Center 05
Flag Claims Units Chgs Paid
-------------------------------------------------
R 0 0.00 0.00 0.00
U 0 0.00 0.00 0.00
B 0 188.50 6974.50 0.00
P 0 3.00 111.00 111.00
D 0 0.00 0.00 0.00
S 0 0.00 0.00 0.00
H 0 2359.00 119763.62 119488.42
T 0 0.00 0.00 0.00
1120 2786.00 170227.72 0.00
Other 0 44.50 2859.66 0.00
-------------------------------------------------
Total 1120 5381.00 299936.50 119599.42
Center 06
Flag Claims Units Chgs Paid
-------------------------------------------------
R 0 0.00 0.00 0.00
U 0 0.00 0.00 0.00
B 0 188.50 6974.50 0.00
P 0 3.00 111.00 111.00
D 0 0.00 0.00 0.00
S 0 0.00 0.00 0.00
H 0 2359.00 119763.62 119488.42
T 0 0.00 0.00 0.00
2688 4985.50 307383.88 0.00
Other 0 44.50 2859.66 0.00
-------------------------------------------------
Total 2688 7580.50 437092.66 119599.42
Center 07
Flag Claims Units Chgs Paid
-------------------------------------------------
R 0 0.00 0.00 0.00
U 0 0.00 0.00 0.00
B 0 188.50 6974.50 0.00
P 0 3.00 111.00 111.00
D 0 0.00 0.00 0.00
S 0 0.00 0.00 0.00
H 0 2359.00 119763.62 119488.42
T 0 0.00 0.00 0.00
630 6623.75 393060.87 0.00
Other 0 44.50 2859.66 0.00
-------------------------------------------------
Total 630 9218.75 522769.65 119599.42
Center 09
Flag Claims Units Chgs Paid
-------------------------------------------------
R 0 0.00 0.00 0.00
U 0 0.00 0.00 0.00
B 0 188.50 6974.50 0.00
P 0 3.00 111.00 111.00
D 0 0.00 0.00 0.00
S 0 0.00 0.00 0.00
H 0 2359.00 119763.62 119488.42
T 0 0.00 0.00 0.00
776 8787.25 527562.86 0.00
Other 0 44.50 2859.66 0.00
-------------------------------------------------
Total 776 11382.25 657271.64 119599.42
Center 10
Flag Claims Units Chgs Paid
-------------------------------------------------
R 0 0.00 0.00 0.00
U 0 0.00 0.00 0.00
B 0 188.50 6974.50 0.00
P 0 3.00 111.00 111.00
D 0 0.00 0.00 0.00
S 0 0.00 0.00 0.00
H 0 2359.00 119763.62 119488.42
T 0 0.00 0.00 0.00
802 10428.75 625296.10 0.00
Other 0 44.50 2859.66 0.00
-------------------------------------------------
Total 802 13023.75 755004.88 119599.42
Center 51
Flag Claims Units Chgs Paid
-------------------------------------------------
R 0 0.00 0.00 0.00
U 0 0.00 0.00 0.00
B 0 188.50 6974.50 0.00
P 0 3.00 111.00 111.00
D 0 0.00 0.00 0.00
S 0 0.00 0.00 0.00
H 0 2359.00 119763.62 119488.42
T 0 0.00 0.00 0.00
882 12624.50 757786.92 0.00
Other 0 44.50 2859.66 0.00
-------------------------------------------------
Total 882 15219.50 887495.70 119599.42
Center 52
Flag Claims Units Chgs Paid
-------------------------------------------------
R 0 0.00 0.00 0.00
U 0 0.00 0.00 0.00
B 0 188.50 6974.50 0.00
P 0 3.00 111.00 111.00
D 0 0.00 0.00 0.00
S 0 0.00 0.00 0.00
H 0 2359.00 119763.62 119488.42
T 0 0.00 0.00 0.00
482 13807.96 834317.42 0.00
Other 0 44.50 2859.66 0.00
-------------------------------------------------
Total 482 16402.96 964026.20 119599.42
Center 53
Flag Claims Units Chgs Paid
-------------------------------------------------
R 0 0.00 0.00 0.00
U 0 0.00 0.00 0.00
B 0 188.50 6974.50 0.00
P 1 4.00 161.00 120.25
D 1 1.00 55.50 0.00
S 0 0.00 0.00 0.00
H 0 2359.00 119763.62 119488.42
T 0 0.00 0.00 0.00
1454 15177.46 905823.39 571.52
Other 0 44.50 2859.66 0.00
-------------------------------------------------
Total 1456 17774.46 1035637.67 120180.19
Center 54
Flag Claims Units Chgs Paid
-------------------------------------------------
R 0 0.00 0.00 0.00
U 0 0.00 0.00 0.00
B 0 188.50 6974.50 0.00
P 0 4.00 161.00 120.25
D 0 1.00 55.50 0.00
S 0 0.00 0.00 0.00
H 0 2359.00 119763.62 119488.42
T 0 0.00 0.00 0.00
537 16535.21 986503.29 571.52
Other 0 44.50 2859.66 0.00
-------------------------------------------------
Total 537 19132.21 1116317.57 120180.19
Center 55
Flag Claims Units Chgs Paid
-------------------------------------------------
R 0 0.00 0.00 0.00
U 0 0.00 0.00 0.00
B 0 188.50 6974.50 0.00
P 0 4.00 161.00 120.25
D 0 1.00 55.50 0.00
S 0 0.00 0.00 0.00
H 0 2359.00 119763.62 119488.42
T 0 0.00 0.00 0.00
1456 17693.21 1061181.31 571.52
Other 0 44.50 2859.66 0.00
-------------------------------------------------
Total 1456 20290.21 1190995.59 120180.19
Center 57
Flag Claims Units Chgs Paid
-------------------------------------------------
R 0 0.00 0.00 0.00
U 0 0.00 0.00 0.00
B 1 189.00 6993.00 0.00
P 7 8.75 336.75 296.00
D 0 1.00 55.50 0.00
S 7 20.00 1000.00 1000.00
H 0 2359.00 119763.62 119488.42
T 13 41.50 2136.58 2136.58
981 20480.46 1209351.70 117000.79
Other 0 44.50 2859.66 0.00
-------------------------------------------------
Total 1009 23144.21 1342496.81 239921.79