CMS/EIP Fiscal Report Statewide
Services beginning 10/01/2009 ending 12/31/2009 Date of Report:02/16/2010 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 101 123.25 4560.25 37.00
Subtotal (Total Children Is Unduplicated) 101 123.25 4560.25 37.00
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Screening, Eval, and Assessment,Class #02
AUDE-92552-PURE TONE AUDIOMETRY -AIR ONLY 3 3.00 31.86 10.62
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 13 13.00 114.79 8.83
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 16 17.00 183.60 10.80
AUDE-92568-ACOUSTIC REFLEX TESTING (MEMR) 3 3.00 25.32 8.44
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 13 13.00 283.27 21.79
AUDE-92585-AUD EVOKED RESPONSE (DIAG) 1 1.00 54.38 54.38
AUDE-92588-OTOACOUSTIC EMISSIONS (COMP) 11 11.00 349.91 31.81
AUDE-V5090-DISPENSING FEE PER HEARING AID 1 1.00 119.60 119.60
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 7 12.00 900.00 75.00
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 1.00 75.00 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 1 2.00 150.00 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 7 11.00 610.50 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 118 175.50 13162.50 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 42 70.50 5287.50 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 55 83.50 6262.50 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 106 173.50 9629.25 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 100 137.50 10238.50 74.46
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 25 25.00 1212.50 48.50
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 68 69.00 3346.50 48.50
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 17 17.00 824.50 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 54 55.00 2667.50 48.50
SPCH-92506-SPEECH EVAL BY LICENSED SLP 137 145.00 7032.50 48.50
Subtotal (Total Children Is Unduplicated) 561 1039.50 62561.98 60.18
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 4 14.00 2582.70 184.48
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 11 35.00 880.00 25.14
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 2496 17186.0 859220.00 50.00
HERN-T1027SC-EI HEARING SERVICES AFTER SHINE 2 16.00 800.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 592 3036.25 206093.87 67.88
OCCT-97530HM-OT SESSION BY OT ASST 24 98.75 5364.10 54.32
PHY-97110-PT SESSION BY LICENSED PT 796 3631.89 246261.23 67.81
PHY-97110HM-PT SESSION BY PT ASST 51 186.75 10144.26 54.32
SENS-V5264-EARMOLD 1 2.00 37.44 18.72
SHIN-T1027SC-INITIAL SHINE SERVICES, INDIVIDUAL 3 8.00 400.00 50.00
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 1207 5800.70 393513.60 67.84
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 4 9.00 488.88 54.32
SPL-92508-GROUP SPL SESSION PER CHILD 20 40.25 531.30 13.20
VISN-T1027SC-EI VISION SERVICES, INDIVIDUAL 1 21.00 1050.00 50.00
Subtotal (Total Children Is Unduplicated) 4003 30085.6 1727367.38 57.42
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Total 31248.34 1794489.61 57.43
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Number of Children (Unduplicated) With at Least One Service 4297
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Center 01
Flag Claims Units Chgs Paid
-------------------------------------------------
R 1 0.25 9.25 0.00
U 0 0.00 0.00 0.00
B 3 3.00 150.00 0.00
P 151 191.50 9575.00 9575.00
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 1 3.00 150.00 200.00
782 1778.25 94560.06 3450.00
Other 549 840.00 49887.32 0.00
-------------------------------------------------
Total 1487 2816.00 154331.63 13225.00
Center 02
Flag Claims Units Chgs Paid
-------------------------------------------------
R 0 0.25 9.25 0.00
U 0 0.00 0.00 0.00
B 0 3.00 150.00 0.00
P 0 191.50 9575.00 9575.00
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 3.00 150.00 200.00
52 1872.25 101044.56 3450.00
Other 0 840.00 49887.32 0.00
-------------------------------------------------
Total 52 2910.00 160816.13 13225.00
Center 04
Flag Claims Units Chgs Paid
-------------------------------------------------
R 0 0.25 9.25 0.00
U 0 0.00 0.00 0.00
B 32 28.75 1102.75 0.00
P 69 249.00 11780.50 11738.00
D 0 0.00 0.00 0.00
S 0 0.00 0.00 0.00
H 1287 4042.50 208806.74 208848.22
T 0 3.00 150.00 200.00
151 2294.75 128788.66 3853.64
Other 0 840.00 49887.32 0.00
-------------------------------------------------
Total 1539 7458.25 400525.22 224639.86
Center 05
Flag Claims Units Chgs Paid
-------------------------------------------------
R 0 0.25 9.25 0.00
U 0 0.00 0.00 0.00
B 0 28.75 1102.75 0.00
P 0 249.00 11780.50 11738.00
D 0 0.00 0.00 0.00
S 0 0.00 0.00 0.00
H 0 4042.50 208806.74 208848.22
T 0 3.00 150.00 200.00
562 2800.00 158198.55 3853.64
Other 0 840.00 49887.32 0.00
-------------------------------------------------
Total 562 7963.50 429935.11 224639.86
Center 06
Flag Claims Units Chgs Paid
-------------------------------------------------
R 0 0.25 9.25 0.00
U 0 0.00 0.00 0.00
B 0 28.75 1102.75 0.00
P 0 249.00 11780.50 11738.00
D 0 0.00 0.00 0.00
S 0 0.00 0.00 0.00
H 0 4042.50 208806.74 208848.22
T 0 3.00 150.00 200.00
2476 4898.75 286782.48 3853.64
Other 0 840.00 49887.32 0.00
-------------------------------------------------
Total 2476 10062.25 558519.04 224639.86
Center 07
Flag Claims Units Chgs Paid
-------------------------------------------------
R 0 0.25 9.25 0.00
U 0 0.00 0.00 0.00
B 0 28.75 1102.75 0.00
P 0 249.00 11780.50 11738.00
D 0 0.00 0.00 0.00
S 0 0.00 0.00 0.00
H 0 4042.50 208806.74 208848.22
T 0 3.00 150.00 200.00
1100 7885.00 450379.16 3853.64
Other 0 840.00 49887.32 0.00
-------------------------------------------------
Total 1100 13048.50 722115.72 224639.86
Center 09
Flag Claims Units Chgs Paid
-------------------------------------------------
R 0 0.25 9.25 0.00
U 0 0.00 0.00 0.00
B 0 28.75 1102.75 0.00
P 0 249.00 11780.50 11738.00
D 0 0.00 0.00 0.00
S 0 0.00 0.00 0.00
H 0 4042.50 208806.74 208848.22
T 0 3.00 150.00 200.00
1446 11683.50 683424.99 3853.64
Other 0 840.00 49887.32 0.00
-------------------------------------------------
Total 1446 16847.00 955161.55 224639.86
Center 10
Flag Claims Units Chgs Paid
-------------------------------------------------
R 0 0.25 9.25 0.00
U 0 0.00 0.00 0.00
B 0 28.75 1102.75 0.00
P 0 249.00 11780.50 11738.00
D 0 0.00 0.00 0.00
S 0 0.00 0.00 0.00
H 0 4042.50 208806.74 208848.22
T 0 3.00 150.00 200.00
1273 14416.25 847657.95 3853.64
Other 0 840.00 49887.32 0.00
-------------------------------------------------
Total 1273 19579.75 1119394.51 224639.86
Center 51
Flag Claims Units Chgs Paid
-------------------------------------------------
R 0 0.25 9.25 0.00
U 0 0.00 0.00 0.00
B 0 28.75 1102.75 0.00
P 0 249.00 11780.50 11738.00
D 0 0.00 0.00 0.00
S 0 0.00 0.00 0.00
H 0 4042.50 208806.74 208848.22
T 0 3.00 150.00 200.00
1060 16936.75 999139.66 3853.64
Other 0 840.00 49887.32 0.00
-------------------------------------------------
Total 1060 22100.25 1270876.22 224639.86
Center 52
Flag Claims Units Chgs Paid
-------------------------------------------------
R 0 0.25 9.25 0.00
U 0 0.00 0.00 0.00
B 0 28.75 1102.75 0.00
P 0 249.00 11780.50 11738.00
D 0 0.00 0.00 0.00
S 0 0.00 0.00 0.00
H 0 4042.50 208806.74 208848.22
T 0 3.00 150.00 200.00
576 18328.59 1088775.89 3853.64
Other 0 840.00 49887.32 0.00
-------------------------------------------------
Total 576 23492.09 1360512.45 224639.86
Center 53
Flag Claims Units Chgs Paid
-------------------------------------------------
R 0 0.25 9.25 0.00
U 0 0.00 0.00 0.00
B 0 28.75 1102.75 0.00
P 0 249.00 11780.50 11738.00
D 0 0.00 0.00 0.00
S 0 0.00 0.00 0.00
H 0 4042.50 208806.74 208848.22
T 0 3.00 150.00 200.00
1925 20106.59 1184058.17 4053.64
Other 0 840.00 49887.32 0.00
-------------------------------------------------
Total 1925 25270.09 1455794.73 224839.86
Center 54
Flag Claims Units Chgs Paid
-------------------------------------------------
R 0 0.25 9.25 0.00
U 0 0.00 0.00 0.00
B 0 28.75 1102.75 0.00
P 0 249.00 11780.50 11738.00
D 0 0.00 0.00 0.00
S 0 0.00 0.00 0.00
H 0 4042.50 208806.74 208848.22
T 0 3.00 150.00 200.00
440 21234.09 1251321.59 4053.64
Other 0 840.00 49887.32 0.00
-------------------------------------------------
Total 440 26397.59 1523058.15 224839.86
Center 55
Flag Claims Units Chgs Paid
-------------------------------------------------
R 0 0.25 9.25 0.00
U 0 0.00 0.00 0.00
B 0 28.75 1102.75 0.00
P 0 249.00 11780.50 11738.00
D 0 0.00 0.00 0.00
S 0 0.00 0.00 0.00
H 0 4042.50 208806.74 208848.22
T 0 3.00 150.00 200.00
1940 22752.84 1347947.03 4053.64
Other 0 840.00 49887.32 0.00
-------------------------------------------------
Total 1940 27916.34 1619683.59 224839.86
Center 57
Flag Claims Units Chgs Paid
-------------------------------------------------
R 1 1.00 37.00 0.00
U 0 0.00 0.00 0.00
B 66 73.75 2767.75 0.00
P 0 249.00 11780.50 11738.00
D 0 0.00 0.00 0.00
S 0 0.00 0.00 0.00
H 0 4042.50 208806.74 208848.22
T 4 22.00 1100.00 1150.00
1075 26020.09 1520110.30 150531.27
Other 0 840.00 49887.32 0.00
-------------------------------------------------
Total 1146 31248.34 1794489.61 372267.49