CMS/EIP Fiscal Report Statewide
Services beginning 07/01/2010 ending 09/30/2010 Date of Report:11/17/2010 Page: 1
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 11247 36776.50000 1359630.7500 36.9701
Subtotal (Total Children Is Unduplicated) 11247 36776.50000 1359630.7500 36.9701
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Screening, Eval, and Assessment,Class #02
AUDE-92552-PURE TONE AUDIOMETRY -AIR ONLY 5 5.000000 53.1000 10.6200
AUDE-92553-PURE TONE AUDIOMETRY AIR & BONE 2 2.000000 32.1600 16.0800
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 83 84.000000 735.1200 8.7514
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 65 67.000000 721.5000 10.7687
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 82 82.000000 1790.6800 21.8376
AUDE-92585-AUD EVOKED RESPONSE (DIAG) 3 3.000000 162.0400 54.0133
AUDE-92586-AUD EVOKED RESPONSE (SCREEN) 1 1.000000 30.4300 30.4300
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 18 18.000000 509.0400 28.2800
AUDE-92588-OTOACOUSTIC EMISSIONS (COMP) 10 10.000000 315.2000 31.5200
BEHV-H0031HO-COMP BEHAVIORAL HEALTH ASSESSMENT 8 11.000000 1375.0000 125.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 102 167.000000 12525.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 24 31.500000 2362.5000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 27 32.500000 2437.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 62 94.500000 7087.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 104 160.500000 8871.7500 55.2757
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 907 1327.500000 99562.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 262 412.500000 30937.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 289 402.000000 30037.5000 74.7201
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 1022 1622.000000 89965.5000 55.4658
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 655 1072.500000 80437.5000 75.0000
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 101 101.000000 18251.5000 180.7079
MED-99204-OUTPATIENT VISIT, NEW, 45 MINS 4 4.000000 229.0800 57.2700
MED-99205-OUTPATIENT VISIT, NEW, 60 MINS 2 2.000000 145.5600 72.7800
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 24 24.000000 2520.0000 105.0000
MED-99215-OUTPATIENT VISIT, EST, 40 MINS 1 1.000000 50.1500 50.1500
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 30 30.000000 1455.0000 48.5000
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 67 72.000000 3492.0000 48.5000
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 19 19.000000 921.5000 48.5000
PSTH-97001-EVAL BY LICENSED PT, INITIAL 90 94.000000 4559.0000 48.5000
SCREEN-T1023-INTERDISCIPLINARY SCREENING 51 51.000000 2550.0000 50.0000
SPCH-92506-SPEECH EVAL BY LICENSED SLP 205 209.000000 10136.5000 48.5000
Subtotal (Total Children Is Unduplicated) 2223 6212.500000 414259.3100 66.6816
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 2 2.000000 488.8300 244.4150
AUD-92630-AUD REHAB PRELING HEARING LOSS 2 4.000000 283.6900 70.9225
COUN-H2019HR-INDIVIDUAL/FAMILY THERAPY 1 9.000000 660.7800 73.4200
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 34 120.000000 3000.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 3640 26010.25000 1300314.5000 49.9924
HERN-T1027SC-EI HEARING SERVICES AFTER SHINE 18 52.000000 2600.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 700 3520.750000 238931.0700 67.8637
OCCT-97530HM-OT SESSION BY OT ASST 60 280.500000 15207.5800 54.2160
PHY-97110-PT SESSION BY LICENSED PT 1009 4779.750000 323405.5600 67.6616
PHY-97110HM-PT SESSION BY PT ASST 34 145.250000 7889.9800 54.3200
SENS-V5264-EARMOLD 1 1.000000 18.0000 18.0000
SHIN-T1027SC-INITIAL SHINE SERVICES, INDIVIDUAL 13 52.000000 2600.0000 50.0000
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 1639 8772.250000 595310.8200 67.8630
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 28 141.000000 7659.1200 54.3200
SPL-92508-GROUP SPL SESSION PER CHILD 31 75.750000 999.9000 13.2000
VISN-T1027SC-EI VISION SERVICES, INDIVIDUAL 5 24.000000 1200.0000 50.0000
Subtotal (Total Children Is Unduplicated) 5476 43989.50000 2500569.8300 56.8447
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Total 86978.500000 4274459.8900 49.1439
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Number of Children (Unduplicated) With at Least One Service 11986
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Center 01
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 790 546.750000 22951.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 4975 3573.500000 143249.7500 0.0000
P 1089 802.250000 34558.0700 32465.5000
D 36 20.000000 816.0000 0.0000
S 154 94.000000 3711.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 1 2.000000 74.0000 0.0000
1509 3417.500000 186159.9100 0.0000
Other 1088 1218.250000 75281.9100 0.0000
---------------------------------------------------------
Total 9642 9674.250000 466802.1400 32465.5000
Center 02
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 6 4.000000 148.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 627 438.250000 16159.7500 0.0000
P 2 1.000000 37.0000 0.0000
D 0 0.000000 0.0000 0.0000
S 4 2.250000 83.2500 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
225 362.750000 19676.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 864 808.250000 36104.0000 0.0000
Center 03
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 10 6.750000 249.7500 0.0000
U 0 0.000000 0.0000 0.0000
B 212 142.000000 5406.0000 9.2500
P 2485 1630.000000 64494.2700 64488.5200
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
0 0.000000 0.0000 0.0000
Other 72 71.250000 1200.1000 0.0000
---------------------------------------------------------
Total 2779 1850.000000 71350.1200 64497.7700
Center 04
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 1 0.750000 27.7500 0.0000
U 0 0.000000 0.0000 0.0000
B 1724 1774.000000 68192.2500 0.0000
P 2396 2453.250000 96693.2500 94178.3000
D 35 35.000000 6155.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 1788 5711.750000 295260.0100 295045.5900
T 0 0.000000 0.0000 0.0000
394 676.000000 49581.6200 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 6338 10650.750000 515909.8800 389223.8900
Center 05
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 2457 1389.250000 52813.7800 0.0000
P 15 20.000000 1450.0000 1450.0000
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
1150 902.750000 45686.2000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 3622 2312.000000 99949.9800 1450.0000
Center 06
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 11 5.750000 212.7500 0.0000
U 0 0.000000 0.0000 0.0000
B 3801 2505.250000 92675.7500 0.0000
P 58 36.500000 1350.5000 1350.5000
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
3651 3036.000000 174055.8200 0.0000
Other 1 0.500000 18.5000 0.0000
---------------------------------------------------------
Total 7522 5584.000000 268313.3200 1350.5000
Center 07
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 80 66.500000 2460.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 2073 1380.750000 54847.2500 0.0000
P 2283 1445.250000 58304.7500 55345.7500
D 14 23.000000 1675.0000 0.0000
S 31 24.750000 915.7500 0.0000
H 0 0.000000 0.0000 0.0000
T 1 1.000000 37.0000 0.0000
1358 4160.750000 224856.0700 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 5840 7102.000000 343096.3200 55345.7500
Center 09
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 12 11.500000 462.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 4934 4598.750000 199677.5300 0.0000
P 417 350.250000 13718.6500 13718.7200
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
1828 5064.750000 309458.2600 0.0000
Other 2 1.500000 55.5000 0.0000
---------------------------------------------------------
Total 7193 10026.750000 523372.4400 13718.7200
Center 10
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 15 6.500000 240.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 359 204.750000 7669.7500 0.0000
P 6931 4530.250000 188690.2500 188690.2500
D 0 0.000000 0.0000 0.0000
S 101 59.500000 2201.5000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
2229 4531.500000 266417.2300 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 9635 9332.500000 465219.2300 188690.2500
Center 51
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 4 3.250000 120.2500 0.0000
U 0 0.000000 0.0000 0.0000
B 3876 2695.000000 101588.9000 0.0000
P 2 1.500000 93.5000 0.0000
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
1257 3216.750000 190706.2600 0.0000
Other 1 0.500000 18.5000 0.0000
---------------------------------------------------------
Total 5140 5917.000000 292527.4100 0.0000
Center 52
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 18 10.250000 527.6500 0.0000
P 2553 1731.500000 78527.5600 78302.5600
D 0 0.000000 0.0000 0.0000
S 14 8.000000 326.8800 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
609 1478.750000 92568.9000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 3194 3228.500000 171950.9900 78302.5600
Center 53
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 80 83.250000 3321.2500 311.0000
U 0 0.000000 0.0000 0.0000
B 1139 1052.500000 43377.0000 0.0000
P 533 589.750000 28981.5000 28194.0000
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
2363 2263.000000 122477.1200 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 4115 3988.500000 198156.8700 28505.0000
Center 54
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 24 18.000000 750.7500 0.0000
U 0 0.000000 0.0000 0.0000
B 2712 1913.500000 79275.0800 0.0000
P 2063 1440.750000 60703.1800 60655.5500
D 13 7.000000 272.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
1064 2659.250000 153721.0300 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 5876 6038.500000 294722.0400 60655.5500
Center 55
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 10 7.500000 277.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 31 37.000000 2262.0000 0.0000
P 1365 1216.500000 46584.2500 46575.0000
D 0 0.000000 0.0000 0.0000
S 4 5.250000 194.2500 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
2670 2193.750000 141795.1900 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 4080 3460.000000 191113.1900 46575.0000
Center 57
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 16 19.500000 721.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 2548 2667.250000 108608.5000 0.0000
P 1 2.000000 74.0000 74.0000
D 0 0.000000 0.0000 0.0000
S 4 7.500000 401.8200 401.8200
H 0 0.000000 0.0000 0.0000
T 1 5.000000 250.0000 250.0000
1450 4304.250000 225816.1400 223048.7700
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 4020 7005.500000 335871.9600 223774.5900