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:Program Patients
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 12652 44061.75000 1627972.0000 36.9475
Subtotal (Total Children Is Unduplicated) 12652 44061.75000 1627972.0000 36.9475
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Screening, Eval, and Assessment,Class #02
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 80 80.000000 662.4000 8.2800
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 52 52.000000 539.7600 10.3800
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 80 80.000000 1686.4000 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 135 228.500000 17137.5000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 38 60.500000 4537.5000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 27 43.000000 3225.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 80 139.000000 10387.5000 74.7302
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 167 271.000000 15032.2500 55.4696
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 1236 1845.500000 138337.5000 74.9594
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 516 806.500000 60337.5000 74.8140
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 312 450.500000 33787.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 1429 2184.500000 121104.0000 55.4379
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 766 1270.500000 95287.5000 75.0000
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 126 126.000000 22876.5000 181.5595
MED-99204-OUTPATIENT VISIT, NEW, 45 MINS 3 3.000000 171.8100 57.2700
MED-99205-OUTPATIENT VISIT, NEW, 60 MINS 3 3.000000 218.3400 72.7800
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 22 22.000000 2310.0000 105.0000
MED-99215-OUTPATIENT VISIT, EST, 40 MINS 2 2.000000 100.3000 50.1500
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 48 48.000000 2328.0000 48.5000
SCREEN-T1023-INTERDISCIPLINARY SCREENING 37 37.000000 1850.0000 50.0000
SPCH-92506-SPEECH EVAL BY LICENSED SLP 92 95.000000 4607.5000 48.5000
Subtotal (Total Children Is Unduplicated) 2762 7974.500000 544496.7300 68.2797
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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 4063 29657.75000 1482729.0000 49.9947
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 1015 5652.643040 383616.6597 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) 5304 42710.33304 2361577.0097 55.2929
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Total 94746.583040 4534045.7397 47.8545
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Number of Children (Unduplicated) With at Least One Service 13229
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Center 01
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 3 2.500000 92.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 1579 1132.000000 46342.5000 0.0000
P 4354 3339.250000 128255.7500 128246.5000
D 111 71.750000 2654.7500 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
1503 3741.000000 197398.5400 0.0000
Other 231 320.500000 22824.4200 0.0000
---------------------------------------------------------
Total 7803 8632.250000 400389.7100 128246.5000
Center 02
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 3 3.000000 111.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 1085 865.250000 31746.0000 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
154 256.750000 18047.2500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 1244 1128.750000 50043.0000 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 60 32.500000 1458.2500 0.0000
P 3953 2490.250000 101092.0000 101085.7500
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 81 80.250000 1336.5000 0.0000
---------------------------------------------------------
Total 4094 2603.000000 103886.7500 101085.7500
Center 04
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 1 0.750000 27.7500 0.0000
U 0 0.000000 0.0000 0.0000
B 2403 2702.750000 102366.7500 0.0000
P 2398 2499.000000 107729.2500 99993.9000
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
608 1148.500000 79621.2200 0.0000
Other 4 4.500000 291.9000 305.4600
---------------------------------------------------------
Total 7100 12024.000000 579003.8100 388089.6400
Center 05
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 2977 1755.750000 67568.3900 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
158 165.500000 9686.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 3135 1921.250000 77254.3900 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 2717 1974.500000 73056.5000 0.0000
P 1288 899.750000 33253.7500 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
2495 2341.750000 133114.8200 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 6500 5216.000000 239425.0700 0.0000
Center 07
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 15 8.750000 323.7500 0.0000
U 0 0.000000 0.0000 0.0000
B 144 86.250000 3191.2500 0.0000
P 4728 3285.000000 130439.0000 130429.7500
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
1247 3333.250000 171852.1100 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 6134 6713.250000 305806.1100 130429.7500
Center 09
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 3 1.750000 64.7500 0.0000
U 0 0.000000 0.0000 0.0000
B 6049 6091.750000 273080.4800 0.0000
P 471 483.750000 18239.8800 18196.7250
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
1607 4866.750000 282459.0500 0.0000
Other 3 1.750000 64.7500 0.0000
---------------------------------------------------------
Total 8133 11445.750000 573908.9100 18196.7250
Center 10
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 47 24.250000 1011.2500 0.0000
U 0 0.000000 0.0000 0.0000
B 1575 1648.500000 92813.5000 6669.2500
P 8248 5082.250000 188043.2500 188043.2500
D 0 0.000000 0.0000 0.0000
S 91 77.250000 2858.2500 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 11637 11306.000000 539418.8400 194712.5000
Center 51
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 2 2.000000 150.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 4399 3168.750000 122211.1700 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
1058 2865.250000 170603.5900 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 5463 6041.750000 293246.9900 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 564 458.750000 24022.6900 0.0000
P 2050 1468.750000 62202.5200 62202.5200
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
433 1084.393040 68713.0197 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 3047 3011.893040 154938.2297 62202.5200
Center 53
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 8 6.000000 222.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 60 48.000000 1928.0000 9.2500
P 2403 2132.250000 85541.7500 85541.7500
D 166 194.750000 11572.4000 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
3228 3314.750000 178386.4500 200.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 5865 5695.750000 277650.6000 85751.0000
Center 54
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 121 86.500000 3200.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 61 55.500000 3227.6200 0.0000
P 2 0.500000 18.5000 18.5000
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
7571 6279.190000 306744.7400 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 7757 6423.440000 313278.8600 18.5000
Center 55
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 28 30.500000 1100.7500 0.0000
P 1543 1529.000000 59397.5000 59397.5000
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
2149 1908.250000 121091.7200 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 3720 3467.750000 181589.9700 59397.5000
Center 57
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 83 88.500000 3274.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 1242 1310.500000 58766.7500 0.0000
P 2071 2014.000000 74555.0000 74475.5800
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
1824 5700.750000 307534.2500 302943.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 5221 9115.750000 444204.5000 377418.5800