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: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 19428 119478 4414427.25 36.95
Subtotal (Total Children Is Unduplicated) 19428 119478 4414427.25 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 6 6.00 96.04 16.01
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 477 492.00 4263.36 8.67
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 411 433.00 4643.22 10.72
AUDE-92568-ACOUSTIC REFLEX TESTING (MEMR) 13 13.00 106.42 8.19
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 435 458.00 9596.62 20.95
AUDE-92585-AUD EVOKED RESPONSE (DIAG) 7 7.00 369.34 52.76
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 60 60.00 1683.72 28.06
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 329 457.50 34229.00 74.82
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 115 172.50 12937.50 75.00
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 179 227.00 17025.00 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 360 505.00 37837.50 74.93
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 464 663.50 36777.50 55.43
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 2184 2991.00 223835.50 74.84
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 967 1544.00 115725.00 74.95
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 1308 1759.50 131722.00 74.86
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 3223 4731.50 262121.75 55.40
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 2467 3605.00 269619.00 74.79
MED-99202-OUTPATIENT VISIT, NEW, 20 MINS 15 15.00 421.88 28.13
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 288 290.00 53167.00 183.33
MED-99204-OUTPATIENT VISIT, NEW, 45 MINS 54 54.00 5427.40 100.51
MED-99205-OUTPATIENT VISIT, NEW, 60 MINS 40 40.00 3038.53 75.96
MED-99212-OUTPATIENT VISIT, EST, 10 MINS 3 3.00 54.51 18.17
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 98 113.00 11865.00 105.00
MED-99214-OUTPATIENT VISIT, EST, 25 MINS 11 11.00 1132.50 102.95
MED-99215-OUTPATIENT VISIT, EST, 40 MINS 17 19.00 1003.01 52.79
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 139 149.00 7211.94 48.40
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 221 238.00 11475.00 48.21
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 162 199.00 9651.50 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 227 235.00 11397.50 48.50
SCREEN-T1023-INTERDISCIPLINARY SCREENING 312 321.00 16050.00 50.00
SPCH-92506-SPEECH EVAL BY LICENSED SLP 478 514.00 24864.52 48.37
Subtotal (Total Children Is Unduplicated) 7772 20371.5 1321401.31 64.87
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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 3648 49343.8 2465286.88 49.96
HERN-T1027SC-EI HEARING SERVICES AFTER SHINE 4 39.00 1950.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 1223 12226.2 828929.21 67.80
OCCT-97530HM-OT SESSION BY OT ASST 168 1856.50 100600.64 54.19
PHY-97110-PT SESSION BY LICENSED PT 1451 15266.4 1034766.80 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 2102 19522.5 1322914.87 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) 6088 101293 5876275.56 58.01
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Total 241142.22 11612104.12 48.15
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Number of Children (Unduplicated) With at Least One Service 19735
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Center 01
Flag Claims Units Chgs Paid
-------------------------------------------------
R 23 14.25 527.25 0.00
U 0 0.00 0.00 0.00
B 3510 2411.75 103568.75 9.25
P 6013 4613.50 202734.39 202496.15
D 1050 764.25 28478.75 0.00
S 1149 978.50 36731.00 0.00
H 13 15.50 904.00 0.00
T 140 171.00 10998.00 10933.50
2661 6756.00 417026.75 0.00
Other 8449 5619.75 222774.11 0.00
-------------------------------------------------
Total 23008 21344.50 1023743.00 213438.90
Center 02
Flag Claims Units Chgs Paid
-------------------------------------------------
R 16 27.50 1017.50 0.00
U 0 0.00 0.00 0.00
B 3874 5429.00 214892.50 9.25
P 0 4613.50 202734.39 202496.15
D 0 764.25 28478.75 0.00
S 0 978.50 36731.00 0.00
H 0 15.50 904.00 0.00
T 0 171.00 10998.00 10933.50
594 7533.75 457192.45 0.00
Other 0 5619.75 222774.11 0.00
-------------------------------------------------
Total 4484 25152.75 1175722.70 213438.90
Center 03
Flag Claims Units Chgs Paid
-------------------------------------------------
R 21 41.75 1544.75 0.00
U 0 0.00 0.00 0.00
B 808 6147.75 246586.51 92.50
P 6088 9332.75 386016.70 385534.96
D 0 764.25 28478.75 0.00
S 2 979.50 36768.00 0.00
H 1 15.75 913.25 9.25
T 0 171.00 10998.00 10933.50
56 7580.25 458969.95 0.00
Other 253 5871.75 226892.26 18.50
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Total 7229 30904.75 1397168.17 396588.71
Center 04
Flag Claims Units Chgs Paid
-------------------------------------------------
R 14 65.25 2414.25 0.00
U 0 0.00 0.00 0.00
B 3457 9466.50 376064.76 92.50
P 13739 21958.25 882273.71 860791.34
D 65 844.00 33018.59 1388.09
S 0 979.50 36768.00 0.00
H 3532 11729.25 593830.47 593626.38
T 0 171.00 10998.00 10933.50
892 9207.25 586916.79 0.00
Other 0 5871.75 226892.26 18.50
-------------------------------------------------
Total 21699 60292.75 2749176.83 1466850.31
Center 05
Flag Claims Units Chgs Paid
-------------------------------------------------
R 70 137.00 7086.04 0.00
U 0 0.00 0.00 0.00
B 9352 14517.50 564133.66 342.50
P 0 21958.25 882273.71 860791.34
D 0 844.00 33018.59 1388.09
S 0 979.50 36768.00 0.00
H 0 11729.25 593830.47 593626.38
T 0 171.00 10998.00 10933.50
6888 13762.00 872068.59 0.00
Other 0 5871.75 226892.26 18.50
-------------------------------------------------
Total 16310 69970.25 3227069.32 1467100.31
Center 06
Flag Claims Units Chgs Paid
-------------------------------------------------
R 2 138.50 7141.54 0.00
U 0 0.00 0.00 0.00
B 7227 19241.50 738899.91 1933.50
P 4380 24822.00 988232.46 966750.09
D 0 844.00 33018.59 1388.09
S 0 979.50 36768.00 0.00
H 0 11729.25 593830.47 593626.38
T 0 171.00 10998.00 10933.50
13542 25669.50 1570858.24 9.25
Other 0 5871.75 226892.26 18.50
-------------------------------------------------
Total 25151 89467.00 4206639.47 1574659.31
Center 07
Flag Claims Units Chgs Paid
-------------------------------------------------
R 1 139.00 7160.04 0.00
U 0 0.00 0.00 0.00
B 5936 23259.50 893524.66 1933.50
P 7642 30378.75 1222837.46 1201289.84
D 4 845.75 33083.34 1388.09
S 472 1317.25 50393.25 0.00
H 0 11729.25 593830.47 593626.38
T 0 171.00 10998.00 10933.50
2079 30742.75 1838158.33 9.25
Other 0 5871.75 226892.26 18.50
-------------------------------------------------
Total 16134 104455.00 4876877.81 1809199.06
Center 09
Flag Claims Units Chgs Paid
-------------------------------------------------
R 162 296.75 15457.27 0.00
U 0 0.00 0.00 0.00
B 2033 25303.00 1003182.84 2580.75
P 11262 41318.50 1715243.79 1824997.52
D 0 845.75 33083.34 1388.09
S 0 1317.25 50393.25 0.00
H 4 11735.50 594061.72 593857.63
T 0 171.00 10998.00 10933.50
2902 38557.50 2332567.57 37.00
Other 0 5871.75 226892.26 18.50
-------------------------------------------------
Total 16363 125417.00 5981880.04 2433812.99
Center 10
Flag Claims Units Chgs Paid
-------------------------------------------------
R 5 298.50 15522.02 0.00
U 0 0.00 0.00 0.00
B 23151 41231.00 1630293.47 2733.75
P 8343 48655.00 2081697.19 2194374.87
D 234 1026.25 40539.84 8945.59
S 186 1435.00 55102.72 0.00
H 0 11735.50 594061.72 593857.63
T 0 171.00 10998.00 10933.50
4189 46535.25 2830884.69 37.00
Other 1 5874.00 226975.51 18.50
-------------------------------------------------
Total 36109 156961.50 7486075.16 2810900.84
Center 51
Flag Claims Units Chgs Paid
-------------------------------------------------
R 3 301.50 15709.02 0.00
U 0 0.00 0.00 0.00
B 12303 49558.25 1947469.83 2733.75
P 1 48656.00 2081765.07 2194374.87
D 1 1027.25 40614.84 8945.59
S 0 1435.00 55102.72 0.00
H 0 11735.50 594061.72 593857.63
T 0 171.00 10998.00 10933.50
3438 54893.00 3328187.07 37.00
Other 0 5874.00 226975.51 18.50
-------------------------------------------------
Total 15746 173651.50 8300883.78 2810900.84
Center 52
Flag Claims Units Chgs Paid
-------------------------------------------------
R 9 309.75 16252.61 0.00
U 0 0.00 0.00 0.00
B 4730 52482.00 2070579.45 2793.91
P 3379 50728.50 2171569.81 2284152.01
D 0 1027.25 40614.84 8945.59
S 9 1460.25 56036.97 0.00
H 0 11735.50 594061.72 593857.63
T 0 171.00 10998.00 10933.50
2279 60120.07 3663278.10 37.00
Other 0 5874.00 226975.51 18.50
-------------------------------------------------
Total 10406 183908.32 8850367.01 2900738.14
Center 53
Flag Claims Units Chgs Paid
-------------------------------------------------
R 1194 1472.50 59287.36 55.50
U 0 0.00 0.00 0.00
B 636 52988.75 2090981.34 5601.04
P 2874 53687.75 2323798.58 2436401.58
D 513 1538.50 66761.73 9373.09
S 16 1478.25 56860.22 0.00
H 0 11735.50 594061.72 593857.63
T 0 171.00 10998.00 10933.50
5182 64936.57 3916405.09 2371.31
Other 8 5882.00 227368.47 115.50
-------------------------------------------------
Total 10423 193890.82 9346522.51 3058709.15
Center 54
Flag Claims Units Chgs Paid
-------------------------------------------------
R 17 1483.75 59694.36 55.50
U 0 0.00 0.00 0.00
B 4722 56155.50 2210572.32 5601.04
P 8392 59400.00 2548857.58 2698467.94
D 11 1546.75 67079.98 9373.09
S 1 1479.00 56887.97 0.00
H 0 11735.50 594061.72 593857.63
T 0 171.00 10998.00 10933.50
4345 73806.72 4432973.01 2371.31
Other 0 5882.00 227368.47 115.50
-------------------------------------------------
Total 17488 211660.2210208493.41 3320775.51
Center 55
Flag Claims Units Chgs Paid
-------------------------------------------------
R 39 1531.25 61451.86 55.50
U 0 0.00 0.00 0.00
B 87 56277.00 2218848.32 5601.04
P 4178 63620.00 2708194.83 2857804.69
D 0 1546.75 67079.98 9373.09
S 36 1520.25 58528.22 0.00
H 0 11735.50 594061.72 593857.63
T 0 171.00 10998.00 10933.50
5759 78369.97 4731501.57 2371.31
Other 1 5882.50 227386.97 115.50
-------------------------------------------------
Total 10100 220654.2210678051.47 3480112.26
Center 57
Flag Claims Units Chgs Paid
-------------------------------------------------
R 287 1869.75 74337.36 55.50
U 0 0.00 0.00 0.00
B 3583 59949.75 2354718.07 5665.79
P 3552 67183.00 2840128.58 2989686.66
D 11 1558.25 67505.48 9373.09
S 26 1585.75 61769.48 3185.76
H 0 11735.50 594061.72 593857.63
T 69 383.50 21770.34 21705.84
4281 90520.97 5346103.60 393051.48
Other 1 5883.00 227405.47 115.50
-------------------------------------------------
Total 11810 240669.4711587800.10 4016697.25
Center 58
Flag Claims Units Chgs Paid
-------------------------------------------------
R 0 1869.75 74337.36 55.50
U 0 0.00 0.00 0.00
B 0 59949.75 2354718.07 5665.79
P 371 67455.75 2853848.73 3003406.81
D 0 1558.25 67505.48 9373.09
S 0 1585.75 61769.48 3185.76
H 0 11735.50 594061.72 593857.63
T 0 383.50 21770.34 21705.84
255 90720.97 5356687.47 393051.48
Other 0 5883.00 227405.47 115.50
-------------------------------------------------
Total 626 241142.2211612104.12 4030417.40