CMS/EIP Fiscal Report Statewide
Services beginning 10/01/2011 ending 12/31/2011 Date of Report:02/15/2012 Page: 1
List order: No List
Agency Filter:EIP DEI DEIP
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 11239 38980.25000 1440621.5000 36.9577
Subtotal (Total Children Is Unduplicated) 11239 38980.25000 1440621.5000 36.9577
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Screening, Eval, and Assessment,Class #02
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 76 76.000000 629.2800 8.2800
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 51 51.000000 529.3800 10.3800
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 76 76.000000 1602.0800 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 71 128.000000 9600.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 22 32.500000 2437.5000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 19 30.000000 2250.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 53 91.000000 6787.5000 74.5879
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 115 183.000000 10148.2500 55.4549
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 555 837.000000 62700.0000 74.9104
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 250 415.500000 31087.5000 74.8195
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 179 264.500000 19837.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 797 1220.000000 67582.5000 55.3955
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 384 617.000000 46275.0000 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
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 1 1.000000 48.5000 48.5000
PSTH-97001-EVAL BY LICENSED PT, INITIAL 4 4.000000 194.0000 48.5000
SCREEN-T1023-INTERDISCIPLINARY SCREENING 30 30.000000 1500.0000 50.0000
SPCH-92506-SPEECH EVAL BY LICENSED SLP 5 7.000000 339.5000 48.5000
Subtotal (Total Children Is Unduplicated) 1519 4212.500000 285901.3300 67.8698
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EI Services,Class #03
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 8 16.000000 400.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 354 1539.250000 76950.0000 49.9919
HERN-T1027SC-EI HEARING SERVICES AFTER SHINE 15 49.500000 2475.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 3 17.250000 1170.9300 67.8800
PHY-97110-PT SESSION BY LICENSED PT 37 128.750000 8739.5500 67.8800
SHIN-T1027SC-INITIAL SHINE SERVICES, INDIVIDUAL 13 23.000000 1150.0000 50.0000
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 27 118.250000 8026.8100 67.8800
VISN-T1027SC-EI VISION SERVICES, INDIVIDUAL 1 2.000000 100.0000 50.0000
Subtotal (Total Children Is Unduplicated) 434 1894.000000 99012.2900 52.2768
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Total 45086.750000 1825535.1200 40.4894
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Number of Children (Unduplicated) With at Least One Service 11282
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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
2 1.000000 56.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 5525 4106.500000 161455.2500 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
7 8.000000 296.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 931 711.750000 26103.5000 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 1968 2289.250000 86193.2500 0.0000
P 2005 2086.750000 87851.7500 82521.1500
D 23 26.000000 999.5000 148.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
184 215.750000 16681.7500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 4181 4618.500000 191754.0000 82669.1500
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
2 1.500000 55.5000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 2598 1505.000000 57600.5600 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
387 515.750000 29757.9800 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 4331 3324.000000 133626.2300 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
10 3.750000 138.7500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 4486 3037.000000 119475.7500 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 5406 5073.250000 219569.4800 0.0000
P 425 409.250000 15273.7500 15316.9750
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 5.750000 212.7500 0.0000
Other 3 1.750000 64.7500 0.0000
---------------------------------------------------------
Total 5844 5491.750000 235185.4800 15316.9750
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
1 0.250000 9.2500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 8922 5793.000000 235762.7500 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 0 0.000000 0.0000 0.0000
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
0 0.000000 0.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 4164 2941.250000 113246.1700 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 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
4 3.250000 120.2500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 2346 1654.250000 73380.4600 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
273 276.250000 10238.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 2631 2308.250000 94550.1500 72413.5000
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
3966 2714.250000 110444.4100 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 4128 2835.750000 115946.7800 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
60 59.750000 3010.7500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 1367 1298.750000 50649.2500 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
38 51.000000 3230.7500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 3185 3146.500000 126067.0000 71358.3300