CMS/EIP Fiscal Report Statewide
Services beginning 01/01/2008 ending 12/31/2008 Date of Report:02/16/2009 Page: 1
Payclass Filters:MED
Eligibility Filter:Not Part C
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 2467 11317.3 417859.50 36.92
Subtotal (Total Children Is Unduplicated) 2467 11317.3 417859.50 36.92
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Screening, Eval, and Assessment,Class #02
AUDE-92553-PURE TONE AUDIOMETRY AIR & BONE 1 1.00 16.30 16.30
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 43 43.00 374.29 8.70
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 36 36.00 386.70 10.74
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 41 41.00 864.65 21.09
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 3 3.00 84.84 28.28
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 35 42.50 3150.00 74.12
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 12 18.50 1387.50 75.00
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 21 23.50 1762.50 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 36 48.50 3637.50 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 56 78.00 4329.00 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 539 714.00 53550.00 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 244 391.50 29325.00 74.90
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 276 344.00 25773.50 74.92
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 774 1135.50 63010.50 55.49
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 471 653.50 48912.50 74.85
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 64 65.00 12120.00 186.46
MED-99204-OUTPATIENT VISIT, NEW, 45 MINS 5 5.00 286.35 57.27
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 1 1.00 105.00 105.00
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 2 2.00 97.00 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 16 17.00 824.50 48.50
SCREEN-T1023-INTERDISCIPLINARY SCREENING 99 99.00 4950.00 50.00
SPCH-92506-SPEECH EVAL BY LICENSED SLP 7 8.00 388.00 48.50
Subtotal (Total Children Is Unduplicated) 1520 3770.50 255335.63 67.72
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 3 18.50 925.00 50.00
PHY-97110-PT SESSION BY LICENSED PT 1 2.00 135.76 67.88
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 1 2.00 135.76 67.88
Subtotal (Total Children Is Unduplicated) 5 22.50 1196.52 53.18
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Total 15110.25 674391.65 44.63
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Number of Children (Unduplicated) With at Least One Service 2545
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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 323 292.50 12620.75 0.00
P 445 338.50 13688.26 13696.51
D 114 106.75 3949.75 0.00
S 108 116.50 4310.50 0.00
H 2 3.00 195.75 0.00
T 10 12.50 801.00 801.00
75 100.00 6588.75 0.00
Other 579 513.75 20306.25 0.00
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Total 1656 1483.50 62461.01 14497.51
Center 02
Flag Claims Units Chgs Paid
-------------------------------------------------
R 6 6.75 249.75 0.00
U 0 0.00 0.00 0.00
B 362 635.75 25321.00 0.00
P 0 338.50 13688.26 13696.51
D 0 106.75 3949.75 0.00
S 0 116.50 4310.50 0.00
H 0 3.00 195.75 0.00
T 0 12.50 801.00 801.00
94 239.75 13834.50 0.00
Other 0 513.75 20306.25 0.00
-------------------------------------------------
Total 462 1973.25 82656.76 14497.51
Center 03
Flag Claims Units Chgs Paid
-------------------------------------------------
R 5 8.75 323.75 0.00
U 0 0.00 0.00 0.00
B 123 758.00 30997.75 0.00
P 788 980.25 39358.01 39325.51
D 0 106.75 3949.75 0.00
S 0 116.50 4310.50 0.00
H 0 3.00 195.75 0.00
T 0 12.50 801.00 801.00
3 242.25 13927.00 0.00
Other 20 533.75 20599.91 0.00
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Total 939 2761.75 114463.42 40126.51
Center 04
Flag Claims Units Chgs Paid
-------------------------------------------------
R 3 17.75 656.75 0.00
U 0 0.00 0.00 0.00
B 211 1042.50 42919.50 0.00
P 848 2157.75 88255.51 84240.38
D 6 112.75 4282.75 0.00
S 0 116.50 4310.50 0.00
H 0 3.00 195.75 0.00
T 0 12.50 801.00 801.00
37 282.50 20516.25 0.00
Other 0 533.75 20599.91 0.00
-------------------------------------------------
Total 1105 4279.00 182537.92 85041.38
Center 05
Flag Claims Units Chgs Paid
-------------------------------------------------
R 0 17.75 656.75 0.00
U 0 0.00 0.00 0.00
B 341 1265.00 51152.00 0.00
P 0 2157.75 88255.51 84240.38
D 0 112.75 4282.75 0.00
S 0 116.50 4310.50 0.00
H 0 3.00 195.75 0.00
T 0 12.50 801.00 801.00
16 300.00 21704.75 0.00
Other 0 533.75 20599.91 0.00
-------------------------------------------------
Total 357 4519.00 191958.92 85041.38
Center 06
Flag Claims Units Chgs Paid
-------------------------------------------------
R 0 17.75 656.75 0.00
U 0 0.00 0.00 0.00
B 497 1644.00 65175.00 0.00
P 330 2411.00 97625.76 93610.63
D 0 112.75 4282.75 0.00
S 0 116.50 4310.50 0.00
H 0 3.00 195.75 0.00
T 0 12.50 801.00 801.00
204 508.00 30070.22 0.00
Other 0 533.75 20599.91 0.00
-------------------------------------------------
Total 1031 5359.25 223717.64 94411.63
Center 07
Flag Claims Units Chgs Paid
-------------------------------------------------
R 0 17.75 656.75 0.00
U 0 0.00 0.00 0.00
B 393 1991.75 79213.25 0.00
P 583 2932.00 120529.01 116513.88
D 1 113.25 4301.25 0.00
S 23 138.75 5355.75 0.00
H 0 3.00 195.75 0.00
T 0 12.50 801.00 801.00
39 577.00 34297.97 0.00
Other 0 533.75 20599.91 0.00
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Total 1039 6319.75 265950.64 117314.88
Center 09
Flag Claims Units Chgs Paid
-------------------------------------------------
R 8 30.75 1439.75 0.00
U 0 0.00 0.00 0.00
B 168 2216.25 92207.76 75.00
P 1167 4390.25 194857.01 190851.08
D 0 113.25 4301.25 0.00
S 0 138.75 5355.75 0.00
H 0 3.00 195.75 0.00
T 0 12.50 801.00 801.00
10 589.25 35101.22 9.25
Other 0 533.75 20599.91 0.00
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Total 1353 8027.75 354859.40 191736.33
Center 10
Flag Claims Units Chgs Paid
-------------------------------------------------
R 0 30.75 1439.75 0.00
U 0 0.00 0.00 0.00
B 1565 3770.25 156724.26 75.00
P 807 5335.50 247090.01 244922.83
D 21 135.00 5372.00 1070.75
S 12 147.50 5679.50 0.00
H 0 3.00 195.75 0.00
T 0 12.50 801.00 801.00
0 589.25 35101.22 9.25
Other 0 533.75 20599.91 0.00
-------------------------------------------------
Total 2405 10557.50 473003.40 246878.83
Center 51
Flag Claims Units Chgs Paid
-------------------------------------------------
R 0 30.75 1439.75 0.00
U 0 0.00 0.00 0.00
B 845 4449.00 182702.76 75.00
P 0 5335.50 247090.01 244922.83
D 0 135.00 5372.00 1070.75
S 0 147.50 5679.50 0.00
H 0 3.00 195.75 0.00
T 0 12.50 801.00 801.00
68 662.25 40367.22 9.25
Other 0 533.75 20599.91 0.00
-------------------------------------------------
Total 913 11309.25 504247.90 246878.83
Center 52
Flag Claims Units Chgs Paid
-------------------------------------------------
R 0 30.75 1439.75 0.00
U 0 0.00 0.00 0.00
B 334 4693.50 192950.26 75.00
P 285 5552.00 256538.76 254365.58
D 0 135.00 5372.00 1070.75
S 1 150.75 5799.75 0.00
H 0 3.00 195.75 0.00
T 0 12.50 801.00 801.00
31 698.25 42496.22 9.25
Other 0 533.75 20599.91 0.00
-------------------------------------------------
Total 651 11809.50 526193.40 256321.58
Center 53
Flag Claims Units Chgs Paid
-------------------------------------------------
R 93 137.25 5380.25 0.00
U 0 0.00 0.00 0.00
B 46 4737.75 194663.51 84.25
P 154 5762.25 268632.76 266459.08
D 44 189.75 8013.50 1070.75
S 0 150.75 5799.75 0.00
H 0 3.00 195.75 0.00
T 0 12.50 801.00 801.00
2 700.25 42581.72 9.25
Other 0 533.75 20599.91 0.00
-------------------------------------------------
Total 339 12227.25 546668.15 268424.33
Center 54
Flag Claims Units Chgs Paid
-------------------------------------------------
R 0 137.25 5380.25 0.00
U 0 0.00 0.00 0.00
B 575 5152.25 210511.01 84.25
P 1079 6599.75 302546.51 300174.83
D 0 189.75 8013.50 1070.75
S 0 150.75 5799.75 0.00
H 0 3.00 195.75 0.00
T 0 12.50 801.00 801.00
170 894.75 54778.97 9.25
Other 0 533.75 20599.91 0.00
-------------------------------------------------
Total 1824 13673.75 608626.65 302140.08
Center 55
Flag Claims Units Chgs Paid
-------------------------------------------------
R 1 137.75 5398.75 0.00
U 0 0.00 0.00 0.00
B 12 5167.25 211560.01 84.25
P 499 7154.00 323738.26 321366.58
D 0 189.75 8013.50 1070.75
S 10 164.25 6356.25 0.00
H 0 3.00 195.75 0.00
T 0 12.50 801.00 801.00
107 1101.75 69390.22 9.25
Other 1 534.25 20618.41 0.00
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Total 630 14464.50 646072.15 323331.83
Center 57
Flag Claims Units Chgs Paid
-------------------------------------------------
R 22 166.25 6529.25 0.00
U 0 0.00 0.00 0.00
B 156 5395.75 220014.51 84.25
P 148 7362.50 331517.51 329145.78
D 0 189.75 8013.50 1070.75
S 0 164.25 6356.25 0.00
H 0 3.00 195.75 0.00
T 0 12.50 801.00 801.00
144 1254.75 79206.72 231.25
Other 0 534.25 20618.41 0.00
-------------------------------------------------
Total 470 15083.00 673252.90 331333.03
Center 58
Flag Claims Units Chgs Paid
-------------------------------------------------
R 0 166.25 6529.25 0.00
U 0 0.00 0.00 0.00
B 0 5395.75 220014.51 84.25
P 18 7378.25 332155.76 329784.03
D 0 189.75 8013.50 1070.75
S 0 164.25 6356.25 0.00
H 0 3.00 195.75 0.00
T 0 12.50 801.00 801.00
19 1266.25 79707.22 231.25
Other 0 534.25 20618.41 0.00
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Total 37 15110.25 674391.65 331971.28