CMS/EIP Fiscal Report Statewide
Services beginning 07/01/2010 ending 09/30/2010 Date of Report:11/17/2010 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 11196 36579.25000 1352332.5000 36.9699
Subtotal (Total Children Is Unduplicated) 11196 36579.25000 1352332.5000 36.9699
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Screening, Eval, and Assessment,Class #02
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 66 66.000000 578.8200 8.7700
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 45 45.000000 486.0000 10.8000
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 63 63.000000 1374.9800 21.8251
AUDE-92585-AUD EVOKED RESPONSE (DIAG) 1 1.000000 54.3800 54.3800
AUDE-92586-AUD EVOKED RESPONSE (SCREEN) 1 1.000000 30.4300 30.4300
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 13 13.000000 367.6400 28.2800
BEHV-H0031HO-COMP BEHAVIORAL HEALTH ASSESSMENT 7 10.000000 1250.0000 125.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 94 156.500000 11737.5000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 18 22.500000 1687.5000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 25 30.000000 2250.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 56 86.500000 6487.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 96 149.500000 8261.2500 55.2592
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 744 1061.500000 79612.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 182 279.000000 20925.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 243 331.000000 24825.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 874 1352.000000 74980.5000 55.4589
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 519 840.500000 63037.5000 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
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 5 5.000000 242.5000 48.5000
PSTH-97001-EVAL BY LICENSED PT, INITIAL 6 6.000000 291.0000 48.5000
SCREEN-T1023-INTERDISCIPLINARY SCREENING 50 50.000000 2500.0000 50.0000
SPCH-92506-SPEECH EVAL BY LICENSED SLP 17 18.000000 873.0000 48.5000
Subtotal (Total Children Is Unduplicated) 1694 4719.000000 323049.2900 68.4571
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EI Services,Class #03
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 3 3.000000 75.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 322 1370.500000 68427.0000 49.9285
HERN-T1027SC-EI HEARING SERVICES AFTER SHINE 13 24.000000 1200.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 20 103.750000 7042.5500 67.8800
PHY-97110-PT SESSION BY LICENSED PT 35 138.750000 9418.3500 67.8800
SHIN-T1027SC-INITIAL SHINE SERVICES, INDIVIDUAL 11 40.000000 2000.0000 50.0000
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 42 192.500000 13066.9000 67.8800
VISN-T1027SC-EI VISION SERVICES, INDIVIDUAL 1 1.000000 50.0000 50.0000
Subtotal (Total Children Is Unduplicated) 424 1873.500000 101279.8000 54.0591
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Total 43171.750000 1776661.5900 41.1533
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Number of Children (Unduplicated) With at Least One Service 11288
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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 1086 799.750000 34406.2500 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
25 13.750000 508.7500 0.0000
Other 157 211.000000 15749.0000 0.0000
---------------------------------------------------------
Total 7224 5260.750000 221466.2500 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
122 175.250000 6598.2500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 761 620.750000 23026.2500 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 1573 1664.000000 64122.2500 0.0000
P 2276 2362.000000 93265.0000 90750.0500
D 35 35.000000 6155.0000 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
96 103.000000 12739.5000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 3981 4164.750000 176309.5000 90750.0500
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
320 170.750000 6317.7500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 2792 1580.000000 60581.5300 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
750 669.250000 30495.4800 0.0000
Other 1 0.500000 18.5000 0.0000
---------------------------------------------------------
Total 4621 3217.250000 124752.9800 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
59 45.000000 1841.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 4541 2986.250000 120081.2500 55345.7500
Center 09
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 11 9.500000 351.5000 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
43 43.500000 1722.5000 0.0000
Other 2 1.500000 55.5000 0.0000
---------------------------------------------------------
Total 5407 5003.500000 215525.6800 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
1 0.500000 18.5000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 7407 4801.500000 198820.5000 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
2 5.000000 250.0000 0.0000
Other 1 0.500000 18.5000 0.0000
---------------------------------------------------------
Total 3885 2705.250000 102071.1500 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
14 13.250000 873.8100 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 2599 1763.000000 80255.9000 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
14 16.250000 566.2500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 1766 1741.750000 76246.0000 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
87 101.000000 3916.3800 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 4899 3480.250000 144917.3900 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
34 32.000000 2112.5800 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 1444 1298.250000 51430.5800 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 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
7 9.750000 422.5100 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 2572 2698.500000 109826.5100 74.0000