CMS/EIP Fiscal Report Statewide
Services beginning 07/01/2009 ending 09/30/2009 Date of Report:11/16/2009 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 68 111.50 4125.50 37.00
Subtotal (Total Children Is Unduplicated) 68 111.50 4125.50 37.00
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Screening, Eval, and Assessment,Class #02
AUD-92626-EVAL OF AUD REHAB STATUS 2 2.00 72.14 36.07
AUDE-92552-PURE TONE AUDIOMETRY -AIR ONLY 4 4.00 42.48 10.62
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 21 21.00 185.43 8.83
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 27 28.00 301.98 10.79
AUDE-92568-ACOUSTIC REFLEX TESTING (MEMR) 1 1.00 8.44 8.44
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 23 23.00 501.17 21.79
AUDE-92585-AUD EVOKED RESPONSE (DIAG) 2 2.00 108.76 54.38
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 2 2.00 56.56 28.28
AUDE-92588-OTOACOUSTIC EMISSIONS (COMP) 14 14.00 445.34 31.81
AUDE-V5010-ASSESSMENT FOR HEARING AID 1 1.00 46.80 46.80
AUDE-V5090-DISPENSING FEE PER HEARING AID 1 2.00 239.20 119.60
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 13 21.50 1612.50 75.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 2 2.50 187.50 75.00
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 3 4.00 300.00 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 6 7.00 525.00 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 6 9.50 527.25 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 154 237.00 17353.50 73.22
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 57 97.00 7222.00 74.45
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 45 69.00 5031.50 72.92
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 126 217.50 12071.25 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 91 124.50 9337.50 75.00
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 36 42.00 2037.00 48.50
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 79 82.00 3977.00 48.50
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 49 49.00 2376.50 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 64 64.00 3104.00 48.50
SPCH-92506-SPEECH EVAL BY LICENSED SLP 152 152.00 7372.00 48.50
Subtotal (Total Children Is Unduplicated) 662 1278.50 75042.80 58.70
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 4 16.00 4868.73 304.30
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 17 66.00 1650.00 25.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 2470 17581.8 878688.50 49.98
HERN-T1027SC-EI HEARING SERVICES AFTER SHINE 3 18.00 900.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 649 3217.00 218319.11 67.86
OCCT-97530HM-OT SESSION BY OT ASST 37 154.25 8378.86 54.32
PHY-97110-PT SESSION BY LICENSED PT 821 3639.75 247012.45 67.87
PHY-97110HM-PT SESSION BY PT ASST 53 256.00 13905.92 54.32
SENS-V5264-EARMOLD 2 6.00 112.32 18.72
SHIN-T1027SC-INITIAL SHINE SERVICES, INDIVIDUAL 1 4.00 200.00 50.00
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 1218 5730.75 388258.71 67.75
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 10 31.00 1683.92 54.32
SPL-92508-GROUP SPL SESSION PER CHILD 10 20.25 268.50 13.26
VISN-T1027SC-EI VISION SERVICES, INDIVIDUAL 3 23.00 1150.00 50.00
Subtotal (Total Children Is Unduplicated) 3987 30763.8 1765397.02 57.39
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Total 32153.75 1844565.32 57.37
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Number of Children (Unduplicated) With at Least One Service 4313
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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 2 2.50 187.50 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
489 1370.25 80120.80 292.88
Other 178 361.50 19971.95 0.00
-------------------------------------------------
Total 669 1734.25 100280.25 292.88
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 2.50 187.50 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
76 1516.25 89991.30 292.88
Other 0 361.50 19971.95 0.00
-------------------------------------------------
Total 76 1880.25 110150.75 292.88
Center 04
Flag Claims Units Chgs Paid
-------------------------------------------------
R 0 0.00 0.00 0.00
U 0 0.00 0.00 0.00
B 79 66.00 2442.00 0.00
P 50 51.25 2013.25 2013.25
D 1 6.50 387.50 200.00
S 0 0.00 0.00 0.00
H 1204 3977.50 202631.50 203191.45
T 0 0.00 0.00 0.00
150 1853.00 111822.75 292.88
Other 0 361.50 19971.95 0.00
-------------------------------------------------
Total 1484 6315.75 339268.95 205697.58
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 66.00 2442.00 0.00
P 0 51.25 2013.25 2013.25
D 0 6.50 387.50 200.00
S 0 0.00 0.00 0.00
H 0 3977.50 202631.50 203191.45
T 0 0.00 0.00 0.00
1047 2648.50 160596.04 292.88
Other 0 361.50 19971.95 0.00
-------------------------------------------------
Total 1047 7111.25 388042.24 205697.58
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 66.00 2442.00 0.00
P 0 51.25 2013.25 2013.25
D 0 6.50 387.50 200.00
S 0 0.00 0.00 0.00
H 0 3977.50 202631.50 203191.45
T 0 0.00 0.00 0.00
2443 4661.00 282568.63 292.88
Other 0 361.50 19971.95 0.00
-------------------------------------------------
Total 2443 9123.75 510014.83 205697.58
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 66.00 2442.00 0.00
P 0 51.25 2013.25 2013.25
D 0 6.50 387.50 200.00
S 0 0.00 0.00 0.00
H 0 3977.50 202631.50 203191.45
T 0 0.00 0.00 0.00
1142 7905.50 459175.29 292.88
Other 0 361.50 19971.95 0.00
-------------------------------------------------
Total 1142 12368.25 686621.49 205697.58
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 66.00 2442.00 0.00
P 1 52.25 2081.13 2081.13
D 0 6.50 387.50 200.00
S 0 0.00 0.00 0.00
H 0 3977.50 202631.50 203191.45
T 0 0.00 0.00 0.00
1192 11230.75 663617.26 292.88
Other 0 361.50 19971.95 0.00
-------------------------------------------------
Total 1193 15694.50 891131.34 205765.46
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 66.00 2442.00 0.00
P 1 55.25 2231.13 2091.13
D 0 6.50 387.50 200.00
S 0 0.00 0.00 0.00
H 0 3977.50 202631.50 203191.45
T 0 0.00 0.00 0.00
1539 14296.75 849231.76 292.88
Other 0 361.50 19971.95 0.00
-------------------------------------------------
Total 1540 18763.50 1076895.84 205775.46
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 66.00 2442.00 0.00
P 0 55.25 2231.13 2091.13
D 0 6.50 387.50 200.00
S 0 0.00 0.00 0.00
H 0 3977.50 202631.50 203191.45
T 0 0.00 0.00 0.00
1019 16865.50 1001588.68 292.88
Other 0 361.50 19971.95 0.00
-------------------------------------------------
Total 1019 21332.25 1229252.76 205775.46
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 66.00 2442.00 0.00
P 0 55.25 2231.13 2091.13
D 0 6.50 387.50 200.00
S 0 0.00 0.00 0.00
H 0 3977.50 202631.50 203191.45
T 0 0.00 0.00 0.00
499 18155.50 1084407.77 292.88
Other 0 361.50 19971.95 0.00
-------------------------------------------------
Total 499 22622.25 1312071.85 205775.46
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 66.00 2442.00 0.00
P 0 55.25 2231.13 2091.13
D 0 6.50 387.50 200.00
S 0 0.00 0.00 0.00
H 0 3977.50 202631.50 203191.45
T 0 0.00 0.00 0.00
2034 20065.25 1185786.98 1092.88
Other 0 361.50 19971.95 0.00
-------------------------------------------------
Total 2034 24532.00 1413451.06 206575.46
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 66.00 2442.00 0.00
P 4 66.25 2781.13 2641.13
D 0 6.50 387.50 200.00
S 0 0.00 0.00 0.00
H 0 3977.50 202631.50 203191.45
T 0 0.00 0.00 0.00
854 22261.25 1314182.11 1092.88
Other 0 361.50 19971.95 0.00
-------------------------------------------------
Total 858 26739.00 1542396.19 207125.46
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 66.00 2442.00 0.00
P 0 66.25 2781.13 2641.13
D 0 6.50 387.50 200.00
S 0 0.00 0.00 0.00
H 0 3977.50 202631.50 203191.45
T 0 0.00 0.00 0.00
2125 23927.00 1421554.60 1092.88
Other 0 361.50 19971.95 0.00
-------------------------------------------------
Total 2125 28404.75 1649768.68 207125.46
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 67.50 2497.50 0.00
P 2 68.00 2845.88 2705.88
D 0 6.50 387.50 200.00
S 0 0.00 0.00 0.00
H 0 3977.50 202631.50 203191.45
T 3 13.00 650.00 650.00
1212 27659.75 1615580.99 176541.79
Other 0 361.50 19971.95 0.00
-------------------------------------------------
Total 1218 32153.75 1844565.32 383289.12