CMS/EIP Fiscal Report Statewide
Services beginning 01/01/2008 ending 12/31/2008 Date of Report:02/17/2009 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 16113 104494 3860962.75 36.95
Subtotal (Total Children Is Unduplicated) 16113 104494 3860962.75 36.95
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Screening, Eval, and Assessment,Class #02
AUD-92626-EVAL OF AUD REHAB STATUS 2 2.00 72.14 36.07
AUDE-92552-PURE TONE AUDIOMETRY -AIR ONLY 10 11.00 118.45 10.77
AUDE-92553-PURE TONE AUDIOMETRY AIR & BONE 5 5.00 79.74 15.95
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 423 438.00 3797.34 8.67
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 364 386.00 4140.24 10.73
AUDE-92568-ACOUSTIC REFLEX TESTING (MEMR) 13 13.00 106.42 8.19
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 384 407.00 8542.81 20.99
AUDE-92585-AUD EVOKED RESPONSE (DIAG) 7 7.00 369.34 52.76
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 55 55.00 1542.32 28.04
AUDE-92588-OTOACOUSTIC EMISSIONS (COMP) 19 20.00 647.36 32.37
AUDE-V5010-ASSESSMENT FOR HEARING AID 2 2.00 90.00 45.00
AUDE-V5090-DISPENSING FEE PER HEARING AID 2 3.00 349.60 116.53
BEHV-H0031HO-COMP BEHAVIORAL HEALTH ASSESSMENT 5 7.00 775.00 110.71
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 267 381.00 28529.00 74.88
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 93 141.50 10612.50 75.00
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 138 178.50 13387.50 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 290 409.00 30675.00 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 363 529.50 29340.50 55.41
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 1611 2231.00 166835.50 74.78
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 705 1129.00 84637.50 74.97
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 983 1356.50 101523.50 74.84
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 2353 3483.00 192839.75 55.37
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 1862 2786.50 208331.50 74.76
MED-99202-OUTPATIENT VISIT, NEW, 20 MINS 14 14.00 387.87 27.71
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 219 220.00 40122.00 182.37
MED-99204-OUTPATIENT VISIT, NEW, 45 MINS 46 46.00 4954.92 107.72
MED-99205-OUTPATIENT VISIT, NEW, 60 MINS 22 22.00 1710.30 77.74
MED-99212-OUTPATIENT VISIT, EST, 10 MINS 3 3.00 54.51 18.17
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 95 110.00 11550.00 105.00
MED-99214-OUTPATIENT VISIT, EST, 25 MINS 11 11.00 1132.50 102.95
MED-99215-OUTPATIENT VISIT, EST, 40 MINS 2 2.00 112.84 56.42
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 138 148.00 7163.44 48.40
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 218 235.00 11329.50 48.21
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 160 197.00 9554.50 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 209 216.00 10476.00 48.50
SCREEN-T1023-INTERDISCIPLINARY SCREENING 189 193.00 9650.00 50.00
SPCH-92506-SPEECH EVAL BY LICENSED SLP 469 504.00 24379.52 48.37
Subtotal (Total Children Is Unduplicated) 5973 15902.5 1019920.91 64.14
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 7 17.00 6926.48 407.44
COUN-H2019HR-INDIVIDUAL/FAMILY THERAPY 6 38.00 2766.54 72.80
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 60 323.00 7780.00 24.09
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 3625 49247.8 2460503.63 49.96
HERN-T1027SC-EI HEARING SERVICES AFTER SHINE 4 39.00 1950.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 1219 12202.7 827334.03 67.80
OCCT-97530HM-OT SESSION BY OT ASST 168 1856.50 100600.64 54.19
PHY-97110-PT SESSION BY LICENSED PT 1445 15218.9 1031542.61 67.78
PHY-97110HM-PT SESSION BY PT ASST 133 1524.00 82703.66 54.27
SENS-V5264-EARMOLD 3 5.00 93.60 18.72
SHIN-T1027SC-INITIAL SHINE SERVICES, INDIVIDUAL 15 26.00 1300.00 50.00
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 2092 19448.5 1317891.75 67.76
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 34 137.75 7482.58 54.32
SPL-92508-GROUP SPL SESSION PER CHILD 86 967.75 12774.30 13.20
Subtotal (Total Children Is Unduplicated) 6052 101052 5861649.82 58.01
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Total 221448.22 10742533.48 48.51
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Number of Children (Unduplicated) With at Least One Service 16337
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Center 01
Flag Claims Units Chgs Paid
-------------------------------------------------
R 21 13.75 508.75 0.00
U 0 0.00 0.00 0.00
B 2958 1955.25 82291.50 9.25
P 5236 4082.25 181706.13 181505.89
D 807 585.50 21865.00 0.00
S 954 787.50 29550.50 0.00
H 10 11.50 633.25 0.00
T 116 144.50 9201.25 9136.75
2537 6600.50 407288.95 0.00
Other 7205 4711.25 186176.36 0.00
-------------------------------------------------
Total 19844 18892.00 919221.69 190651.89
Center 02
Flag Claims Units Chgs Paid
-------------------------------------------------
R 10 20.25 749.25 0.00
U 0 0.00 0.00 0.00
B 3512 4629.25 180915.00 9.25
P 0 4082.25 181706.13 181505.89
D 0 585.50 21865.00 0.00
S 0 787.50 29550.50 0.00
H 0 11.50 633.25 0.00
T 0 144.50 9201.25 9136.75
500 7238.50 440208.90 0.00
Other 0 4711.25 186176.36 0.00
-------------------------------------------------
Total 4022 22210.50 1051005.64 190651.89
Center 03
Flag Claims Units Chgs Paid
-------------------------------------------------
R 16 32.50 1202.50 0.00
U 0 0.00 0.00 0.00
B 685 5225.75 206932.26 92.50
P 5292 8156.50 339198.44 338795.45
D 0 585.50 21865.00 0.00
S 2 788.50 29587.50 0.00
H 1 11.75 642.50 9.25
T 0 144.50 9201.25 9136.75
53 7282.50 441893.90 0.00
Other 233 4943.25 190000.85 18.50
-------------------------------------------------
Total 6282 27170.75 1240524.20 348052.45
Center 04
Flag Claims Units Chgs Paid
-------------------------------------------------
R 10 46.25 1711.25 0.00
U 0 0.00 0.00 0.00
B 3087 8142.25 320051.01 92.50
P 12166 19114.50 767981.95 750892.12
D 57 657.25 25979.34 1351.09
S 0 788.50 29587.50 0.00
H 3525 11703.25 592459.72 592526.38
T 0 144.50 9201.25 9136.75
850 8865.00 562650.24 0.00
Other 0 4943.25 190000.85 18.50
-------------------------------------------------
Total 19695 54404.75 2499623.11 1354017.34
Center 05
Flag Claims Units Chgs Paid
-------------------------------------------------
R 50 98.00 5263.95 0.00
U 0 0.00 0.00 0.00
B 7950 12359.75 476713.39 142.50
P 0 19114.50 767981.95 750892.12
D 0 657.25 25979.34 1351.09
S 0 788.50 29587.50 0.00
H 0 11703.25 592459.72 592526.38
T 0 144.50 9201.25 9136.75
6816 13360.75 843897.49 0.00
Other 0 4943.25 190000.85 18.50
-------------------------------------------------
Total 14816 63169.75 2941085.44 1354067.34
Center 06
Flag Claims Units Chgs Paid
-------------------------------------------------
R 2 99.50 5319.45 0.00
U 0 0.00 0.00 0.00
B 6094 16343.50 624090.39 1678.00
P 3753 21560.25 858474.70 841384.87
D 0 657.25 25979.34 1351.09
S 0 788.50 29587.50 0.00
H 0 11703.25 592459.72 592526.38
T 0 144.50 9201.25 9136.75
13255 24974.75 1530430.86 9.25
Other 0 4943.25 190000.85 18.50
-------------------------------------------------
Total 23104 81214.75 3865544.06 1446104.84
Center 07
Flag Claims Units Chgs Paid
-------------------------------------------------
R 1 100.00 5337.95 0.00
U 0 0.00 0.00 0.00
B 5538 20011.00 764575.14 1678.00
P 7020 26556.75 1068459.20 1051304.12
D 3 658.50 26025.59 1351.09
S 449 1104.00 42167.50 0.00
H 0 11703.25 592459.72 592526.38
T 0 144.50 9201.25 9136.75
2040 29979.00 1793503.20 9.25
Other 0 4943.25 190000.85 18.50
-------------------------------------------------
Total 15051 95200.25 4491730.40 1656024.09
Center 09
Flag Claims Units Chgs Paid
-------------------------------------------------
R 154 244.75 12852.18 0.00
U 0 0.00 0.00 0.00
B 1865 21830.00 861238.81 2250.25
P 10095 36038.25 1486537.53 1600674.60
D 0 658.50 26025.59 1351.09
S 0 1104.00 42167.50 0.00
H 4 11709.50 592690.97 592757.63
T 0 144.50 9201.25 9136.75
2892 37781.50 2287109.19 27.75
Other 0 4943.25 190000.85 18.50
-------------------------------------------------
Total 15010 114454.25 5507823.87 2206216.57
Center 10
Flag Claims Units Chgs Paid
-------------------------------------------------
R 5 246.50 12916.93 0.00
U 0 0.00 0.00 0.00
B 20766 35446.50 1392140.94 2403.25
P 7080 41934.25 1775423.68 1890647.45
D 198 797.75 31689.84 7116.34
S 174 1213.00 46553.22 0.00
H 0 11709.50 592690.97 592757.63
T 0 144.50 9201.25 9136.75
4186 45756.25 2785222.67 27.75
Other 0 4943.25 190000.85 18.50
-------------------------------------------------
Total 32409 142191.50 6835840.35 2502107.67
Center 51
Flag Claims Units Chgs Paid
-------------------------------------------------
R 3 249.50 13103.93 0.00
U 0 0.00 0.00 0.00
B 11371 43037.00 1681154.80 2403.25
P 1 41935.25 1775491.56 1890647.45
D 1 798.75 31764.84 7116.34
S 0 1213.00 46553.22 0.00
H 0 11709.50 592690.97 592757.63
T 0 144.50 9201.25 9136.75
3336 53968.50 3272521.69 27.75
Other 0 4943.25 190000.85 18.50
-------------------------------------------------
Total 14712 157999.25 7612483.11 2502107.67
Center 52
Flag Claims Units Chgs Paid
-------------------------------------------------
R 9 257.75 13647.52 0.00
U 0 0.00 0.00 0.00
B 4349 45682.50 1792626.42 2463.41
P 3061 43770.50 1854974.30 1970108.69
D 0 798.75 31764.84 7116.34
S 8 1235.00 47367.22 0.00
H 0 11709.50 592690.97 592757.63
T 0 144.50 9201.25 9136.75
2244 59155.57 3605288.22 27.75
Other 0 4943.25 190000.85 18.50
-------------------------------------------------
Total 9671 167697.32 8137561.59 2581629.07
Center 53
Flag Claims Units Chgs Paid
-------------------------------------------------
R 1091 1308.00 52519.77 55.50
U 0 0.00 0.00 0.00
B 589 46144.75 1811305.81 5261.29
P 2696 46499.50 1994062.32 2109218.01
D 459 1248.50 54963.48 7543.84
S 16 1253.00 48190.47 0.00
H 0 11709.50 592690.97 592757.63
T 0 144.50 9201.25 9136.75
5180 63970.07 3858329.71 2362.06
Other 8 4951.25 190393.81 115.50
-------------------------------------------------
Total 10039 177229.07 8611657.59 2726450.58
Center 54
Flag Claims Units Chgs Paid
-------------------------------------------------
R 17 1319.25 52926.77 55.50
U 0 0.00 0.00 0.00
B 4077 48861.75 1913745.04 5261.29
P 7188 51312.00 2182781.07 2335142.12
D 11 1256.75 55281.73 7543.84
S 1 1253.75 48218.22 0.00
H 0 11709.50 592690.97 592757.63
T 0 144.50 9201.25 9136.75
4152 72602.72 4359829.16 2362.06
Other 0 4951.25 190393.81 115.50
-------------------------------------------------
Total 15446 193411.47 9405068.02 2952374.69
Center 55
Flag Claims Units Chgs Paid
-------------------------------------------------
R 38 1366.25 54665.77 55.50
U 0 0.00 0.00 0.00
B 75 48968.25 1920972.04 5261.29
P 3679 54977.75 2320926.57 2473287.12
D 0 1256.75 55281.73 7543.84
S 26 1281.50 49301.97 0.00
H 0 11709.50 592690.97 592757.63
T 0 144.50 9201.25 9136.75
5652 76958.97 4643746.47 2362.06
Other 0 4951.25 190393.81 115.50
-------------------------------------------------
Total 9470 201614.72 9837180.58 3090519.69
Center 57
Flag Claims Units Chgs Paid
-------------------------------------------------
R 265 1676.25 66420.77 55.50
U 0 0.00 0.00 0.00
B 3426 52412.25 2048378.04 5326.04
P 3400 58326.00 2444849.82 2597158.64
D 11 1268.25 55707.23 7543.84
S 25 1346.75 52533.98 3185.76
H 0 11709.50 592690.97 592757.63
T 69 357.00 19973.59 19909.09
4135 88954.97 5248401.50 392820.23
Other 1 4951.75 190412.31 115.50
-------------------------------------------------
Total 11332 221002.7210719368.21 3618872.23
Center 58
Flag Claims Units Chgs Paid
-------------------------------------------------
R 0 1676.25 66420.77 55.50
U 0 0.00 0.00 0.00
B 0 52412.25 2048378.04 5326.04
P 353 58583.00 2457931.72 2610240.54
D 0 1268.25 55707.23 7543.84
S 0 1346.75 52533.98 3185.76
H 0 11709.50 592690.97 592757.63
T 0 357.00 19973.59 19909.09
236 89143.47 5258484.87 392820.23
Other 0 4951.75 190412.31 115.50
-------------------------------------------------
Total 589 221448.2210742533.48 3631954.13