CMS/EIP Fiscal Report Statewide
Services beginning 10/01/2009 ending 12/31/2009 Date of Report:02/16/2010 Page: 1
Agency Filter:EIP DEI DEIP
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 10005 31503.3 1164149.00 36.95
Subtotal (Total Children Is Unduplicated) 10005 31503.3 1164149.00 36.95
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Screening, Eval, and Assessment,Class #02
AUDE-92553-PURE TONE AUDIOMETRY AIR & BONE 1 1.00 16.30 16.30
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 54 55.00 485.65 8.83
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 40 41.00 442.80 10.80
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 50 51.00 1111.29 21.79
AUDE-92586-AUD EVOKED RESPONSE (SCREEN) 2 2.00 60.86 30.43
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 7 7.00 197.96 28.28
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 56 83.00 6225.00 75.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 17 24.00 1800.00 75.00
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 30 41.50 3112.50 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 48 82.50 6187.50 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 70 101.00 5605.50 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 525 769.00 57675.00 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 219 349.00 26175.00 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 187 246.00 18450.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 620 967.00 53668.50 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 348 577.50 43237.50 74.87
MED-99202-OUTPATIENT VISIT, NEW, 20 MINS 1 1.00 27.22 27.22
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 92 92.00 16297.50 177.15
MED-99204-OUTPATIENT VISIT, NEW, 45 MINS 15 15.00 1076.78 71.79
MED-99205-OUTPATIENT VISIT, NEW, 60 MINS 2 2.00 145.56 72.78
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 23 23.00 2415.00 105.00
MED-99214-OUTPATIENT VISIT, EST, 25 MINS 1 1.00 160.00 160.00
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 1 1.00 48.50 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 1 1.00 48.50 48.50
SCREEN-T1023-INTERDISCIPLINARY SCREENING 45 45.00 2250.00 50.00
SPCH-92506-SPEECH EVAL BY LICENSED SLP 10 10.00 485.00 48.50
Subtotal (Total Children Is Unduplicated) 1342 3588.50 247405.42 68.94
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EI Services,Class #03
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 17 19.00 475.00 25.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 293 1337.50 66862.50 49.99
HERN-T1027SC-EI HEARING SERVICES AFTER SHINE 9 23.50 1175.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 25 136.25 9248.65 67.88
OCCT-97530HM-OT SESSION BY OT ASST 1 1.50 81.48 54.32
PHY-97110-PT SESSION BY LICENSED PT 24 106.00 7195.28 67.88
SHIN-T1027SC-INITIAL SHINE SERVICES, INDIVIDUAL 13 29.00 1450.00 50.00
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 51 226.25 15357.85 67.88
SPL-92508-GROUP SPL SESSION PER CHILD 1 4.00 52.80 13.20
Subtotal (Total Children Is Unduplicated) 399 1883.00 101898.56 54.12
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Total 36974.75 1513452.98 40.93
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Number of Children (Unduplicated) With at Least One Service 10128
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Center 01
Flag Claims Units Chgs Paid
-------------------------------------------------
R 247 163.25 6227.50 0.00
U 0 0.00 0.00 0.00
B 3181 2269.25 85541.75 0.00
P 1 0.25 9.25 9.25
D 135 182.50 12085.50 0.00
S 2017 1494.00 55139.25 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
216 142.50 5443.50 0.00
Other 43 74.50 4661.25 0.00
-------------------------------------------------
Total 5840 4326.25 169108.00 9.25
Center 02
Flag Claims Units Chgs Paid
-------------------------------------------------
R 17 176.75 6727.00 0.00
U 0 0.00 0.00 0.00
B 649 2805.75 105179.00 0.00
P 1 0.75 27.75 9.25
D 0 182.50 12085.50 0.00
S 1 1495.25 55185.50 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
43 194.75 7330.50 0.00
Other 0 74.50 4661.25 0.00
-------------------------------------------------
Total 711 4930.25 191196.50 9.25
Center 03
Flag Claims Units Chgs Paid
-------------------------------------------------
R 47 217.75 8449.50 0.00
U 0 0.00 0.00 0.00
B 62 2852.50 107003.25 0.00
P 2227 1581.50 62933.00 62886.75
D 0 182.50 12085.50 0.00
S 0 1495.25 55185.50 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
107 285.25 10716.00 0.00
Other 70 144.50 5763.92 0.00
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Total 2513 6759.25 262136.67 62886.75
Center 04
Flag Claims Units Chgs Paid
-------------------------------------------------
R 283 521.00 20423.75 0.00
U 0 0.00 0.00 0.00
B 1704 4594.75 178517.25 0.00
P 1907 3545.25 135739.75 135557.18
D 0 182.50 12085.50 0.00
S 0 1495.25 55185.50 0.00
H 0 0.00 0.00 0.00
T 1 1.25 46.25 0.00
211 494.50 33137.25 0.00
Other 0 144.50 5763.92 0.00
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Total 4106 10979.00 440899.17 135557.18
Center 05
Flag Claims Units Chgs Paid
-------------------------------------------------
R 133 603.00 23457.75 0.00
U 0 0.00 0.00 0.00
B 1813 5539.25 213634.75 0.00
P 0 3545.25 135739.75 135557.18
D 0 182.50 12085.50 0.00
S 0 1495.25 55185.50 0.00
H 0 0.00 0.00 0.00
T 0 1.25 46.25 0.00
141 585.00 36485.75 0.00
Other 0 144.50 5763.92 0.00
-------------------------------------------------
Total 2087 12096.00 482399.17 135557.18
Center 06
Flag Claims Units Chgs Paid
-------------------------------------------------
R 25 617.75 24003.50 0.00
U 0 0.00 0.00 0.00
B 165 5644.25 217519.75 434.75
P 3484 5788.00 219158.50 218975.93
D 0 182.50 12085.50 0.00
S 0 1495.25 55185.50 0.00
H 0 0.00 0.00 0.00
T 0 1.25 46.25 0.00
583 1108.25 63347.19 0.00
Other 0 144.50 5763.92 0.00
-------------------------------------------------
Total 4257 14981.75 597110.11 219410.68
Center 07
Flag Claims Units Chgs Paid
-------------------------------------------------
R 232 765.75 29479.50 0.00
U 0 0.00 0.00 0.00
B 4023 8263.00 323360.06 434.75
P 346 5988.00 226532.75 226350.18
D 0 182.50 12085.50 0.00
S 5 1500.50 55379.75 0.00
H 0 0.00 0.00 0.00
T 0 1.25 46.25 0.00
39 1132.75 64330.69 0.00
Other 0 144.50 5763.92 0.00
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Total 4645 17978.25 716978.42 226784.93
Center 09
Flag Claims Units Chgs Paid
-------------------------------------------------
R 107 836.25 32170.50 0.00
U 0 0.00 0.00 0.00
B 2955 10733.00 436813.72 481.00
P 686 6613.50 255785.43 338634.36
D 0 182.50 12085.50 0.00
S 0 1500.50 55379.75 0.00
H 0 0.00 0.00 0.00
T 0 1.25 46.25 0.00
41 1165.25 65651.95 0.00
Other 0 144.50 5763.92 0.00
-------------------------------------------------
Total 3789 21176.75 863697.02 339115.36
Center 10
Flag Claims Units Chgs Paid
-------------------------------------------------
R 607 1195.25 45566.50 0.00
U 0 0.00 0.00 0.00
B 5946 14514.25 586428.72 481.00
P 502 7106.00 283754.18 366547.61
D 0 182.50 12085.50 0.00
S 118 1564.50 57747.75 0.00
H 0 0.00 0.00 0.00
T 0 1.25 46.25 0.00
0 1165.25 65651.95 0.00
Other 0 144.50 5763.92 0.00
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Total 7173 25873.50 1057044.77 367028.61
Center 51
Flag Claims Units Chgs Paid
-------------------------------------------------
R 57 1237.00 47301.25 0.00
U 0 0.00 0.00 0.00
B 3148 16935.00 677118.78 481.00
P 0 7106.00 283754.18 366547.61
D 0 182.50 12085.50 0.00
S 0 1564.50 57747.75 0.00
H 0 0.00 0.00 0.00
T 1 2.25 83.25 0.00
5 1170.00 65903.70 0.00
Other 0 144.50 5763.92 0.00
-------------------------------------------------
Total 3211 28341.75 1149758.33 367028.61
Center 52
Flag Claims Units Chgs Paid
-------------------------------------------------
R 234 1415.00 56328.01 0.00
U 0 0.00 0.00 0.00
B 880 17500.00 703468.25 481.00
P 1202 7790.00 309456.18 392249.61
D 0 182.50 12085.50 0.00
S 67 1616.75 59607.00 0.00
H 0 0.00 0.00 0.00
T 0 2.25 83.25 0.00
51 1226.50 69370.95 0.00
Other 0 144.50 5763.92 0.00
-------------------------------------------------
Total 2434 29877.50 1216163.06 392730.61
Center 53
Flag Claims Units Chgs Paid
-------------------------------------------------
R 334 1761.00 72393.39 0.00
U 0 0.00 0.00 0.00
B 595 17936.25 720320.50 481.00
P 1302 8975.00 363618.18 446411.61
D 4 187.50 12385.50 0.00
S 0 1616.75 59607.00 0.00
H 0 0.00 0.00 0.00
T 0 2.25 83.25 0.00
4 1230.75 69528.20 0.00
Other 0 144.50 5763.92 0.00
-------------------------------------------------
Total 2239 31854.00 1303699.94 446892.61
Center 54
Flag Claims Units Chgs Paid
-------------------------------------------------
R 68 1826.00 75247.89 0.00
U 0 0.00 0.00 0.00
B 1842 19380.00 780955.68 481.00
P 2080 10470.50 425443.54 508199.09
D 40 216.00 13848.98 0.00
S 0 1616.75 59607.00 0.00
H 0 0.00 0.00 0.00
T 0 2.25 83.25 0.00
29 1255.00 70668.96 0.00
Other 0 144.50 5763.92 0.00
-------------------------------------------------
Total 4059 34911.00 1431619.22 508680.09
Center 55
Flag Claims Units Chgs Paid
-------------------------------------------------
R 20 1848.25 76072.64 0.00
U 0 0.00 0.00 0.00
B 247 19587.25 788392.68 481.00
P 808 11201.75 454060.29 536806.59
D 0 216.00 13848.98 0.00
S 2 1619.25 59699.50 0.00
H 0 0.00 0.00 0.00
T 0 2.25 83.25 0.00
11 1262.50 71008.22 0.00
Other 0 144.50 5763.92 0.00
-------------------------------------------------
Total 1088 35881.75 1468929.48 537287.59
Center 57
Flag Claims Units Chgs Paid
-------------------------------------------------
R 181 2027.75 82798.89 0.00
U 0 0.00 0.00 0.00
B 875 20492.25 825734.18 481.00
P 1 11203.75 454134.29 536880.59
D 0 216.00 13848.98 0.00
S 0 1619.25 59699.50 0.00
H 0 0.00 0.00 0.00
T 0 2.25 83.25 0.00
7 1269.00 71389.97 0.00
Other 0 144.50 5763.92 0.00
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Total 1064 36974.75 1513452.98 537361.59