CMS/EIP Fiscal Report Statewide
Services beginning 07/01/2008 ending 09/30/2008 Date of Report:11/18/2008 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 8385 25640.8 947211.25 36.94
Subtotal (Total Children Is Unduplicated) 8385 25640.8 947211.25 36.94
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Screening, Eval, and Assessment,Class #02
AUD-92626-EVAL OF AUD REHAB STATUS 1 1.00 36.07 36.07
AUDE-92552-PURE TONE AUDIOMETRY -AIR ONLY 2 2.00 21.24 10.62
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 106 106.00 935.98 8.83
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 93 93.00 1003.98 10.80
AUDE-92568-ACOUSTIC REFLEX TESTING (MEMR) 1 1.00 8.44 8.44
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 95 95.00 2070.05 21.79
AUDE-92585-AUD EVOKED RESPONSE (DIAG) 1 1.00 54.38 54.38
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 13 13.00 367.64 28.28
AUDE-92588-OTOACOUSTIC EMISSIONS (COMP) 5 5.00 159.05 31.81
AUDE-V5090-DISPENSING FEE PER HEARING AID 1 1.00 119.60 119.60
BEHV-H0031HO-COMP BEHAVIORAL HEALTH ASSESSMENT 1 1.00 50.00 50.00
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 73 106.00 7950.00 75.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 15 22.00 1650.00 75.00
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 43 54.50 4087.50 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 65 93.50 7012.50 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 98 146.00 8091.25 55.42
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 427 579.75 43239.50 74.58
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 206 318.50 23887.50 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 237 311.50 23287.50 74.76
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 592 853.50 47255.25 55.37
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 404 579.50 43350.00 74.81
MED-99202-OUTPATIENT VISIT, NEW, 20 MINS 2 2.00 54.44 27.22
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 73 73.00 13360.50 183.02
MED-99204-OUTPATIENT VISIT, NEW, 45 MINS 12 12.00 1558.16 129.85
MED-99205-OUTPATIENT VISIT, NEW, 60 MINS 6 6.00 436.68 72.78
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 28 28.00 2940.00 105.00
MED-99214-OUTPATIENT VISIT, EST, 25 MINS 2 2.00 69.00 34.50
MED-99215-OUTPATIENT VISIT, EST, 40 MINS 1 1.00 50.15 50.15
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 35 35.00 1697.50 48.50
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 50 52.00 2522.00 48.50
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 47 58.00 2813.00 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 46 46.00 2231.00 48.50
SCREEN-T1023-INTERDISCIPLINARY SCREENING 39 39.00 1950.00 50.00
SPCH-92506-SPEECH EVAL BY LICENSED SLP 116 119.00 5771.50 48.50
Subtotal (Total Children Is Unduplicated) 1534 3856.75 250091.36 64.85
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 4 15.00 1490.75 99.38
COUN-H2019HR-INDIVIDUAL/FAMILY THERAPY 2 13.00 954.46 73.42
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 16 48.00 1195.00 24.90
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 1898 12468.5 622895.63 49.96
HERN-T1027SC-EI HEARING SERVICES AFTER SHINE 3 8.00 400.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 592 2806.75 190454.39 67.86
OCCT-97530HM-OT SESSION BY OT ASST 66 247.75 13457.78 54.32
PHY-97110-PT SESSION BY LICENSED PT 799 3543.25 240431.96 67.86
PHY-97110HM-PT SESSION BY PT ASST 42 243.75 13187.18 54.10
SENS-V5264-EARMOLD 1 2.00 37.44 18.72
SHIN-T1027SC-INITIAL SHINE SERVICES, INDIVIDUAL 3 4.00 200.00 50.00
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 1015 4570.50 310126.25 67.85
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 17 45.50 2471.56 54.32
SPL-92508-GROUP SPL SESSION PER CHILD 14 30.50 402.60 13.20
Subtotal (Total Children Is Unduplicated) 3240 24046.5 1397705.00 58.13
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Total 53544.00 2595007.61 48.46
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Number of Children (Unduplicated) With at Least One Service 8925
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Center 01
Flag Claims Units Chgs Paid
-------------------------------------------------
R 0 0.00 0.00 0.00
U 0 0.00 0.00 0.00
B 0 0.00 0.00 0.00
P 0 0.00 0.00 0.00
D 0 0.00 0.00 0.00
S 971 594.50 22024.25 0.00
H 3 3.00 150.00 0.00
T 103 135.00 8831.00 8831.00
701 1655.25 99097.63 0.00
Other 3846 2397.50 94283.40 0.00
-------------------------------------------------
Total 5624 4785.25 224386.28 8831.00
Center 02
Flag Claims Units Chgs Paid
-------------------------------------------------
R 34 21.50 795.50 0.00
U 0 0.00 0.00 0.00
B 883 723.00 26686.25 0.00
P 0 0.00 0.00 0.00
D 0 0.00 0.00 0.00
S 0 594.50 22024.25 0.00
H 0 3.00 150.00 0.00
T 0 135.00 8831.00 8831.00
84 1784.25 105841.38 0.00
Other 0 2397.50 94283.40 0.00
-------------------------------------------------
Total 1001 5658.75 258611.78 8831.00
Center 03
Flag Claims Units Chgs Paid
-------------------------------------------------
R 4 24.50 906.50 0.00
U 0 0.00 0.00 0.00
B 203 923.25 36107.25 0.00
P 894 708.75 26299.75 26242.25
D 0 0.00 0.00 0.00
S 0 594.50 22024.25 0.00
H 0 3.00 150.00 0.00
T 0 135.00 8831.00 8831.00
28 1811.50 107134.63 0.00
Other 46 2443.50 95006.99 0.00
-------------------------------------------------
Total 1175 6644.00 296460.37 35073.25
Center 04
Flag Claims Units Chgs Paid
-------------------------------------------------
R 22 73.00 2701.00 0.00
U 0 0.00 0.00 0.00
B 3800 4512.00 169993.50 0.00
P 122 823.75 35111.01 33837.99
D 39 41.50 2599.44 283.94
S 0 594.50 22024.25 0.00
H 940 3144.50 159225.90 159543.60
T 0 135.00 8831.00 8831.00
328 2301.00 146993.65 0.00
Other 0 2443.50 95006.99 0.00
-------------------------------------------------
Total 5251 14068.75 642486.74 202496.53
Center 05
Flag Claims Units Chgs Paid
-------------------------------------------------
R 19 92.00 3965.05 0.00
U 0 0.00 0.00 0.00
B 1907 5514.00 207067.50 0.00
P 0 823.75 35111.01 33837.99
D 0 41.50 2599.44 283.94
S 0 594.50 22024.25 0.00
H 0 3144.50 159225.90 159543.60
T 0 135.00 8831.00 8831.00
1684 3379.00 214427.21 0.00
Other 0 2443.50 95006.99 0.00
-------------------------------------------------
Total 3610 16167.75 748258.35 202496.53
Center 06
Flag Claims Units Chgs Paid
-------------------------------------------------
R 1 92.50 3983.55 0.00
U 0 0.00 0.00 0.00
B 2568 7194.75 269255.25 0.00
P 0 823.75 35111.01 33837.99
D 0 41.50 2599.44 283.94
S 0 594.50 22024.25 0.00
H 0 3144.50 159225.90 159543.60
T 0 135.00 8831.00 8831.00
3054 6001.75 369352.17 0.00
Other 0 2443.50 95006.99 0.00
-------------------------------------------------
Total 5623 20471.75 965389.56 202496.53
Center 07
Flag Claims Units Chgs Paid
-------------------------------------------------
R 2 93.50 4020.55 0.00
U 0 0.00 0.00 0.00
B 2846 9013.50 336988.25 0.00
P 94 1001.25 47621.26 46348.24
D 0 41.50 2599.44 283.94
S 206 729.25 27084.00 0.00
H 0 3144.50 159225.90 159543.60
T 0 135.00 8831.00 8831.00
588 7452.75 445544.55 0.00
Other 0 2443.50 95006.99 0.00
-------------------------------------------------
Total 3736 24054.75 1126921.94 215006.78
Center 09
Flag Claims Units Chgs Paid
-------------------------------------------------
R 22 110.25 5044.10 0.00
U 0 0.00 0.00 0.00
B 527 9541.25 366609.58 77.75
P 2426 3167.50 142434.52 168157.75
D 0 41.50 2599.44 283.94
S 0 729.25 27084.00 0.00
H 1 3146.25 159290.65 159608.35
T 0 135.00 8831.00 8831.00
797 9516.25 576031.38 0.00
Other 2 2444.75 95053.24 0.00
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Total 3775 28832.00 1382977.91 336958.79
Center 10
Flag Claims Units Chgs Paid
-------------------------------------------------
R 2 112.00 5108.85 0.00
U 0 0.00 0.00 0.00
B 6251 13525.50 515479.33 77.75
P 596 3976.75 195453.27 221229.25
D 75 101.00 5351.94 3036.44
S 0 729.25 27084.00 0.00
H 0 3146.25 159290.65 159608.35
T 0 135.00 8831.00 8831.00
1081 11524.50 700384.38 0.00
Other 0 2444.75 95053.24 0.00
-------------------------------------------------
Total 8005 35695.00 1712036.66 392782.79
Center 51
Flag Claims Units Chgs Paid
-------------------------------------------------
R 0 112.00 5108.85 0.00
U 0 0.00 0.00 0.00
B 2949 15453.50 588304.09 77.75
P 2 3989.75 196323.00 222031.10
D 0 101.00 5351.94 3036.44
S 0 729.25 27084.00 0.00
H 1 3148.25 159440.65 159608.35
T 1 135.50 8849.50 8831.00
806 13519.00 819562.09 0.00
Other 0 2444.75 95053.24 0.00
-------------------------------------------------
Total 3759 39633.00 1905077.36 393584.64
Center 52
Flag Claims Units Chgs Paid
-------------------------------------------------
R 0 112.00 5108.85 0.00
U 0 0.00 0.00 0.00
B 1674 16455.00 631099.26 77.75
P 121 4053.25 198672.50 224380.60
D 0 101.00 5351.94 3036.44
S 1 729.50 27093.25 0.00
H 0 3148.25 159440.65 159608.35
T 0 135.50 8849.50 8831.00
538 14788.25 902267.04 0.00
Other 0 2444.75 95053.24 0.00
-------------------------------------------------
Total 2334 41967.50 2032936.23 395934.14
Center 53
Flag Claims Units Chgs Paid
-------------------------------------------------
R 54 136.50 6080.35 50.00
U 0 0.00 0.00 0.00
B 459 16793.00 644567.89 87.00
P 110 4163.25 204072.50 229780.60
D 0 101.00 5351.94 3036.44
S 0 729.50 27093.25 0.00
H 2 3150.25 159540.65 159708.35
T 0 135.50 8849.50 8831.00
1491 16241.25 979271.73 447.00
Other 4 2448.75 95270.08 0.00
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Total 2120 43899.00 2130097.89 401940.39
Center 54
Flag Claims Units Chgs Paid
-------------------------------------------------
R 0 136.50 6080.35 50.00
U 0 0.00 0.00 0.00
B 1962 18144.25 696498.89 87.00
P 696 4631.25 221286.75 246984.85
D 0 101.00 5351.94 3036.44
S 0 729.50 27093.25 0.00
H 0 3150.25 159540.65 159708.35
T 0 135.50 8849.50 8831.00
1077 18342.25 1097059.39 447.00
Other 0 2448.75 95270.08 0.00
-------------------------------------------------
Total 3735 47819.25 2317030.80 419144.64
Center 55
Flag Claims Units Chgs Paid
-------------------------------------------------
R 0 136.50 6080.35 50.00
U 0 0.00 0.00 0.00
B 129 18299.00 702680.64 87.00
P 745 5370.00 249115.00 274813.10
D 0 101.00 5351.94 3036.44
S 11 742.25 27565.00 0.00
H 0 3150.25 159540.65 159708.35
T 0 135.50 8849.50 8831.00
1085 19216.75 1153061.23 447.00
Other 0 2448.75 95270.08 0.00
-------------------------------------------------
Total 1970 49600.00 2407514.39 446972.89
Center 57
Flag Claims Units Chgs Paid
-------------------------------------------------
R 0 136.50 6080.35 50.00
U 0 0.00 0.00 0.00
B 1033 19255.50 738084.14 105.50
P 408 5744.00 262953.00 288632.60
D 0 101.00 5351.94 3036.44
S 8 769.25 28915.00 1350.00
H 0 3150.25 159540.65 159708.35
T 21 203.50 12249.50 12231.00
980 21735.25 1286562.95 106914.39
Other 0 2448.75 95270.08 0.00
-------------------------------------------------
Total 2450 53544.00 2595007.61 572028.28