CMS/EIP Fiscal Report Statewide
Services beginning 10/01/2011 ending 12/31/2011 Date of Report:02/16/2012 Page: 1
List order: No List
Payclass Filters:MED
Eligibility Filter:Part C (excluding not eligible)
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 11279 39104.50000 1445218.7500 36.9579
Subtotal (Total Children Is Unduplicated) 11279 39104.50000 1445218.7500 36.9579
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Screening, Eval, and Assessment,Class #02
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 77 77.000000 637.5600 8.2800
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 51 51.000000 529.3800 10.3800
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 77 77.000000 1623.1600 21.0800
AUDE-92585-AUD EVOKED RESPONSE (DIAG) 2 2.000000 103.5200 51.7600
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 5 5.000000 135.9500 27.1900
BEHV-H0031HO-COMP BEHAVIORAL HEALTH ASSESSMENT 18 25.000000 3125.0000 125.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 95 166.500000 12487.5000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 24 35.500000 2662.5000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 22 34.500000 2587.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 67 116.500000 8700.0000 74.6781
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 128 202.500000 11230.5000 55.4593
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 832 1259.000000 94350.0000 74.9404
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 349 564.000000 42150.0000 74.7340
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 216 313.000000 23475.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 922 1421.500000 78765.7500 55.4103
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 559 957.500000 71812.5000 75.0000
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 90 90.000000 16361.0000 181.7889
MED-99204-OUTPATIENT VISIT, NEW, 45 MINS 3 3.000000 171.8100 57.2700
MED-99205-OUTPATIENT VISIT, NEW, 60 MINS 2 2.000000 145.5600 72.7800
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 22 22.000000 2310.0000 105.0000
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 21 21.000000 1018.5000 48.5000
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 52 53.000000 2570.5000 48.5000
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 21 21.000000 1018.5000 48.5000
PSTH-97001-EVAL BY LICENSED PT, INITIAL 47 47.000000 2279.5000 48.5000
SCREEN-T1023-INTERDISCIPLINARY SCREENING 30 30.000000 1500.0000 50.0000
SPCH-92506-SPEECH EVAL BY LICENSED SLP 92 95.000000 4607.5000 48.5000
Subtotal (Total Children Is Unduplicated) 1974 5691.500000 386358.6900 67.8835
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 10 47.000000 9333.5200 198.5855
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 19 60.000000 1483.5000 24.7250
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 4058 29623.75000 1481029.0000 49.9946
HERN-T1027SC-EI HEARING SERVICES AFTER SHINE 26 125.500000 6275.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 525 2896.250000 196495.7500 67.8449
OCCT-97530HM-OT SESSION BY OT ASST 46 213.000000 11570.1600 54.3200
PHY-97110-PT SESSION BY LICENSED PT 770 3738.190000 253461.9800 67.8034
PHY-97110HM-PT SESSION BY PT ASST 51 188.500000 10239.3200 54.3200
SHIN-T1027SC-INITIAL SHINE SERVICES, INDIVIDUAL 19 50.000000 2500.0000 50.0000
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 1014 5651.893040 383565.7497 67.8650
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 19 51.000000 2770.3200 54.3200
SPL-92508-GROUP SPL SESSION PER CHILD 4 11.500000 151.8000 13.2000
VISN-T1027SC-EI VISION SERVICES, INDIVIDUAL 3 19.000000 950.0000 50.0000
Subtotal (Total Children Is Unduplicated) 5298 42675.58304 2359826.0997 55.2969
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Total 87471.583040 4191403.5397 47.9173
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Number of Children (Unduplicated) With at Least One Service 11845
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Center 01
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 2 2.000000 74.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 1439 1011.500000 41104.7500 0.0000
P 3962 3008.250000 115234.7500 115234.7500
D 98 58.500000 2164.5000 0.0000
S 21 24.000000 2775.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 1 1.250000 46.2500 0.0000
1493 3713.500000 195950.0400 0.0000
Other 178 254.000000 17836.9200 0.0000
---------------------------------------------------------
Total 7194 8073.000000 375186.2100 115234.7500
Center 02
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 3 3.000000 111.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 919 697.000000 25557.7500 0.0000
P 0 0.000000 0.0000 0.0000
D 0 0.000000 0.0000 0.0000
S 2 3.750000 138.7500 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
98 175.000000 12245.7500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 1022 878.750000 38053.2500 0.0000
Center 03
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 51 26.000000 1046.7500 0.0000
P 3625 2215.250000 88447.0000 88437.7500
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 74 73.250000 1238.0400 0.0000
---------------------------------------------------------
Total 3750 2314.500000 90731.7900 88437.7500
Center 04
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 1 0.750000 27.7500 0.0000
U 0 0.000000 0.0000 0.0000
B 2112 2350.250000 88450.2500 0.0000
P 2103 2122.500000 89174.5000 83843.9000
D 23 26.000000 999.5000 148.0000
S 0 0.000000 0.0000 0.0000
H 1663 5642.500000 287967.4400 287642.2800
T 0 0.000000 0.0000 0.0000
578 1107.750000 75741.9700 0.0000
Other 4 4.500000 291.9000 305.4600
---------------------------------------------------------
Total 6484 11254.250000 542653.3100 371939.6400
Center 05
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 2596 1503.500000 57545.0600 0.0000
P 0 0.000000 0.0000 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
142 145.500000 8186.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 2738 1649.000000 65731.0600 0.0000
Center 06
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 2681 1936.000000 71632.0000 0.0000
P 1263 872.250000 32236.2500 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
2475 2314.250000 131052.3200 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 6419 5122.500000 234920.5700 0.0000
Center 07
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 14 8.250000 305.2500 0.0000
U 0 0.000000 0.0000 0.0000
B 119 72.250000 2673.2500 0.0000
P 4343 2952.750000 116358.5000 116349.2500
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
1223 3293.250000 169277.1100 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 5699 6326.500000 288614.1100 116349.2500
Center 09
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 3 1.750000 64.7500 0.0000
U 0 0.000000 0.0000 0.0000
B 5407 5075.250000 219719.4800 0.0000
P 426 410.250000 15341.6300 15335.4750
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
1606 4865.500000 282412.8000 0.0000
Other 3 1.750000 64.7500 0.0000
---------------------------------------------------------
Total 7445 10354.500000 517603.4100 15335.4750
Center 10
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 43 21.250000 900.2500 0.0000
U 0 0.000000 0.0000 0.0000
B 1253 1214.250000 66235.0000 5587.0000
P 7542 4491.250000 166176.2500 166176.2500
D 0 0.000000 0.0000 0.0000
S 83 66.000000 2442.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
1676 4473.750000 254692.5900 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 10597 10266.500000 490446.0900 171763.2500
Center 51
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 2 2.000000 150.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 4159 2935.750000 112966.6700 0.0000
P 1 2.250000 152.7300 152.7300
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 3 3.500000 129.5000 0.0000
T 0 0.000000 0.0000 0.0000
1035 2840.750000 168909.5900 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 5200 5784.250000 282308.4900 152.7300
Center 52
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 504 396.000000 20545.4400 0.0000
P 1838 1255.000000 52714.7700 52714.7700
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
425 1071.893040 67775.5197 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 2767 2722.893040 141035.7297 52714.7700
Center 53
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 8 6.000000 222.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 53 40.500000 1613.5000 9.2500
P 2141 1810.750000 72404.2500 72404.2500
D 156 174.750000 10072.4000 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
3125 3164.000000 170117.2000 200.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 5483 5196.000000 254429.3500 72613.5000
Center 54
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 102 69.000000 2553.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 57 50.500000 2852.6200 0.0000
P 1 0.250000 9.2500 9.2500
D 2 1.750000 87.5000 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
6865 5579.190000 273400.0800 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 7027 5700.690000 278902.4500 9.2500
Center 55
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 13 14.000000 490.2500 0.0000
P 1294 1225.000000 47148.2500 47148.2500
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
2095 1814.000000 114139.2200 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 3402 3053.000000 161777.7200 47148.2500
Center 57
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 75 75.250000 2784.2500 0.0000
U 0 0.000000 0.0000 0.0000
B 1060 1088.500000 48540.2500 0.0000
P 2011 1929.750000 71437.7500 71358.3300
D 1 2.000000 74.0000 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
1807 5679.750000 306173.7500 302943.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 4954 8775.250000 429010.0000 374301.3300