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:Program Patients
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 9536 29122.0 1075684.50 36.94
Subtotal (Total Children Is Unduplicated) 9536 29122.0 1075684.50 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) 117 117.00 1033.11 8.83
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 102 102.00 1101.18 10.80
AUDE-92568-ACOUSTIC REFLEX TESTING (MEMR) 1 1.00 8.44 8.44
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 105 105.00 2287.95 21.79
AUDE-92585-AUD EVOKED RESPONSE (DIAG) 1 1.00 54.38 54.38
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 17 17.00 480.76 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 87 121.50 9075.00 74.69
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 18 27.00 2025.00 75.00
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 51 62.50 4687.50 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 77 107.50 8062.50 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 112 166.50 9229.00 55.43
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 579 779.75 58239.50 74.69
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 275 431.00 32325.00 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 326 415.50 31061.00 74.76
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 808 1165.50 64571.25 55.40
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 509 714.00 53412.50 74.81
MED-99202-OUTPATIENT VISIT, NEW, 20 MINS 2 2.00 54.44 27.22
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 93 93.00 17060.50 183.45
MED-99204-OUTPATIENT VISIT, NEW, 45 MINS 16 16.00 1787.24 111.70
MED-99205-OUTPATIENT VISIT, NEW, 60 MINS 13 13.00 946.14 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 7 7.00 351.05 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 50 50.00 2425.00 48.50
SCREEN-T1023-INTERDISCIPLINARY SCREENING 67 67.00 3350.00 50.00
SPCH-92506-SPEECH EVAL BY LICENSED SLP 117 120.00 5820.00 48.50
Subtotal (Total Children Is Unduplicated) 1953 4886.75 319875.90 65.46
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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 1906 12491.0 624020.63 49.96
HERN-T1027SC-EI HEARING SERVICES AFTER SHINE 3 8.00 400.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 594 2811.75 190793.79 67.86
OCCT-97530HM-OT SESSION BY OT ASST 66 247.75 13457.78 54.32
PHY-97110-PT SESSION BY LICENSED PT 800 3548.25 240771.36 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 1019 4586.50 311212.33 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) 3254 24095.0 1400594.88 58.13
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Total 58103.75 2796155.28 48.12
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Number of Children (Unduplicated) With at Least One Service 10115
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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 1085 687.75 25474.50 0.00
H 5 6.00 345.75 0.00
T 132 166.50 10938.75 10938.75
737 1693.25 101211.28 0.00
Other 4480 2813.75 110160.90 0.00
-------------------------------------------------
Total 6439 5367.25 248131.18 10938.75
Center 02
Flag Claims Units Chgs Paid
-------------------------------------------------
R 34 21.50 795.50 0.00
U 0 0.00 0.00 0.00
B 953 793.25 29285.50 0.00
P 0 0.00 0.00 0.00
D 0 0.00 0.00 0.00
S 0 687.75 25474.50 0.00
H 0 6.00 345.75 0.00
T 0 166.50 10938.75 10938.75
86 1825.75 108122.53 0.00
Other 0 2813.75 110160.90 0.00
-------------------------------------------------
Total 1073 6314.50 285123.43 10938.75
Center 03
Flag Claims Units Chgs Paid
-------------------------------------------------
R 4 24.50 906.50 0.00
U 0 0.00 0.00 0.00
B 224 1020.00 40168.25 0.00
P 1000 802.25 29759.25 29701.75
D 0 0.00 0.00 0.00
S 0 687.75 25474.50 0.00
H 0 6.00 345.75 0.00
T 0 166.50 10938.75 10938.75
36 1861.00 109844.78 0.00
Other 53 2866.75 110987.15 0.00
-------------------------------------------------
Total 1317 7434.75 328424.93 40640.50
Center 04
Flag Claims Units Chgs Paid
-------------------------------------------------
R 22 73.00 2701.00 0.00
U 0 0.00 0.00 0.00
B 4203 5065.00 191047.75 0.00
P 148 937.25 40322.51 38656.58
D 45 47.50 2932.44 283.94
S 0 687.75 25474.50 0.00
H 943 3156.50 159871.65 159993.60
T 0 166.50 10938.75 10938.75
347 2372.50 153033.80 0.00
Other 0 2866.75 110987.15 0.00
-------------------------------------------------
Total 5708 15372.75 697309.55 209872.87
Center 05
Flag Claims Units Chgs Paid
-------------------------------------------------
R 32 105.00 4661.06 0.00
U 0 0.00 0.00 0.00
B 2315 6322.00 237556.75 0.00
P 0 937.25 40322.51 38656.58
D 0 47.50 2932.44 283.94
S 0 687.75 25474.50 0.00
H 0 3156.50 159871.65 159993.60
T 0 166.50 10938.75 10938.75
1708 3472.50 221886.60 0.00
Other 0 2866.75 110987.15 0.00
-------------------------------------------------
Total 4055 17761.75 814631.41 209872.87
Center 06
Flag Claims Units Chgs Paid
-------------------------------------------------
R 1 105.50 4679.56 0.00
U 0 0.00 0.00 0.00
B 2972 8262.50 309355.25 0.00
P 0 937.25 40322.51 38656.58
D 0 47.50 2932.44 283.94
S 0 687.75 25474.50 0.00
H 0 3156.50 159871.65 159993.60
T 0 166.50 10938.75 10938.75
3114 6158.00 379721.08 0.00
Other 0 2866.75 110987.15 0.00
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Total 6087 22388.25 1044282.89 209872.87
Center 07
Flag Claims Units Chgs Paid
-------------------------------------------------
R 2 106.50 4716.56 0.00
U 0 0.00 0.00 0.00
B 3035 10240.50 383221.25 0.00
P 106 1135.75 54378.51 52712.58
D 0 47.50 2932.44 283.94
S 218 834.75 31098.50 0.00
H 0 3156.50 159871.65 159993.60
T 0 166.50 10938.75 10938.75
593 7616.25 456311.21 0.00
Other 0 2866.75 110987.15 0.00
-------------------------------------------------
Total 3954 26171.00 1214456.02 223928.87
Center 09
Flag Claims Units Chgs Paid
-------------------------------------------------
R 23 124.25 5790.11 0.00
U 0 0.00 0.00 0.00
B 553 10800.75 414763.08 152.75
P 2742 3711.75 170242.77 195573.09
D 0 47.50 2932.44 283.94
S 0 834.75 31098.50 0.00
H 1 3158.25 159936.40 160058.35
T 0 166.50 10938.75 10938.75
813 9696.75 587965.79 0.00
Other 2 2868.00 111033.40 0.00
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Total 4134 31408.50 1494701.24 367006.88
Center 10
Flag Claims Units Chgs Paid
-------------------------------------------------
R 2 126.00 5854.86 0.00
U 0 0.00 0.00 0.00
B 6921 15373.75 585896.33 152.75
P 760 4765.75 239844.02 265227.09
D 92 127.00 6670.94 4022.44
S 0 834.75 31098.50 0.00
H 0 3158.25 159936.40 160058.35
T 0 166.50 10938.75 10938.75
1084 11708.00 712522.43 0.00
Other 0 2868.00 111033.40 0.00
-------------------------------------------------
Total 8859 39128.00 1863795.63 440399.38
Center 51
Flag Claims Units Chgs Paid
-------------------------------------------------
R 0 126.00 5854.86 0.00
U 0 0.00 0.00 0.00
B 3137 17441.50 664043.84 152.75
P 2 4778.75 240713.75 266028.94
D 0 127.00 6670.94 4022.44
S 0 834.75 31098.50 0.00
H 1 3160.25 160086.40 160058.35
T 1 167.00 10957.25 10938.75
821 13724.50 833149.32 0.00
Other 0 2868.00 111033.40 0.00
-------------------------------------------------
Total 3962 43227.75 2063608.26 441201.23
Center 52
Flag Claims Units Chgs Paid
-------------------------------------------------
R 0 126.00 5854.86 0.00
U 0 0.00 0.00 0.00
B 1848 18585.50 713131.51 152.75
P 141 4850.75 243377.75 268692.94
D 0 127.00 6670.94 4022.44
S 1 835.00 31107.75 0.00
H 0 3160.25 160086.40 160058.35
T 0 167.00 10957.25 10938.75
544 14999.75 916154.27 0.00
Other 0 2868.00 111033.40 0.00
-------------------------------------------------
Total 2534 45719.25 2198374.13 443865.23
Center 53
Flag Claims Units Chgs Paid
-------------------------------------------------
R 64 154.75 6983.61 50.00
U 0 0.00 0.00 0.00
B 500 18963.50 728193.64 162.00
P 110 4960.75 248777.75 274092.94
D 0 127.00 6670.94 4022.44
S 0 835.00 31107.75 0.00
H 2 3162.25 160186.40 160158.35
T 0 167.00 10957.25 10938.75
1508 16478.75 994717.96 447.00
Other 4 2872.00 111250.24 0.00
-------------------------------------------------
Total 2188 47721.00 2298845.54 449871.48
Center 54
Flag Claims Units Chgs Paid
-------------------------------------------------
R 0 154.75 6983.61 50.00
U 0 0.00 0.00 0.00
B 2253 20525.00 787972.64 162.00
P 806 5520.00 269275.75 294488.44
D 0 127.00 6670.94 4022.44
S 0 835.00 31107.75 0.00
H 0 3162.25 160186.40 160158.35
T 0 167.00 10957.25 10938.75
1128 18641.75 1116264.14 447.00
Other 0 2872.00 111250.24 0.00
-------------------------------------------------
Total 4187 52004.75 2500668.72 470266.98
Center 55
Flag Claims Units Chgs Paid
-------------------------------------------------
R 0 154.75 6983.61 50.00
U 0 0.00 0.00 0.00
B 139 20692.25 794673.89 162.00
P 853 6381.50 301798.25 327010.94
D 0 127.00 6670.94 4022.44
S 11 847.75 31579.50 0.00
H 0 3162.25 160186.40 160158.35
T 0 167.00 10957.25 10938.75
1137 19604.00 1177767.73 447.00
Other 0 2872.00 111250.24 0.00
-------------------------------------------------
Total 2140 54008.50 2601867.81 502789.48
Center 57
Flag Claims Units Chgs Paid
-------------------------------------------------
R 0 154.75 6983.61 50.00
U 0 0.00 0.00 0.00
B 1095 21737.25 833351.89 180.50
P 425 6775.25 316367.00 341561.19
D 0 127.00 6670.94 4022.44
S 8 874.75 32929.50 1350.00
H 0 3162.25 160186.40 160158.35
T 21 235.00 14357.25 14338.75
1023 22165.50 1314058.45 106914.39
Other 0 2872.00 111250.24 0.00
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Total 2572 58103.75 2796155.28 628575.62