CMS/EIP Fiscal Report Statewide
Services beginning 10/01/2008 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 8505 26027.3 961891.75 36.96
Subtotal (Total Children Is Unduplicated) 8505 26027.3 961891.75 36.96
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Screening, Eval, and Assessment,Class #02
AUDE-92552-PURE TONE AUDIOMETRY -AIR ONLY 6 6.00 63.72 10.62
AUDE-92553-PURE TONE AUDIOMETRY AIR & BONE 2 2.00 32.60 16.30
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 70 70.00 618.10 8.83
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 62 62.00 669.60 10.80
AUDE-92568-ACOUSTIC REFLEX TESTING (MEMR) 7 7.00 59.08 8.44
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 70 70.00 1525.30 21.79
AUDE-92585-AUD EVOKED RESPONSE (DIAG) 1 1.00 54.38 54.38
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 6 6.00 169.68 28.28
AUDE-92588-OTOACOUSTIC EMISSIONS (COMP) 8 8.00 254.48 31.81
BEHV-H0031HO-COMP BEHAVIORAL HEALTH ASSESSMENT 3 5.00 550.00 110.00
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 71 98.00 7330.50 74.80
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 25 36.50 2737.50 75.00
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 31 39.00 2925.00 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 52 76.50 5737.50 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 84 109.00 6049.50 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 582 820.00 61396.00 74.87
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 208 341.00 25575.00 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 271 397.00 29711.00 74.84
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 603 877.50 48585.25 55.37
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 459 762.00 57076.50 74.90
MED-99202-OUTPATIENT VISIT, NEW, 20 MINS 3 3.00 81.66 27.22
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 57 57.00 10400.50 182.46
MED-99204-OUTPATIENT VISIT, NEW, 45 MINS 12 12.00 1340.43 111.70
MED-99205-OUTPATIENT VISIT, NEW, 60 MINS 4 4.00 291.12 72.78
MED-99212-OUTPATIENT VISIT, EST, 10 MINS 2 2.00 36.34 18.17
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 36 36.00 3780.00 105.00
MED-99214-OUTPATIENT VISIT, EST, 25 MINS 2 2.00 194.50 97.25
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 25 25.00 1212.50 48.50
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 44 46.00 2231.00 48.50
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 36 36.00 1746.00 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 41 41.00 1988.50 48.50
SCREEN-T1023-INTERDISCIPLINARY SCREENING 63 66.00 3300.00 50.00
SPCH-92506-SPEECH EVAL BY LICENSED SLP 98 98.00 4753.00 48.50
Subtotal (Total Children Is Unduplicated) 1652 4221.50 282476.24 66.91
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EI Services,Class #03
COUN-H2019HR-INDIVIDUAL/FAMILY THERAPY 3 13.00 931.04 71.62
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 19 51.00 1275.00 25.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 1966 12677.5 633875.00 50.00
HERN-T1027SC-EI HEARING SERVICES AFTER SHINE 4 14.00 700.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 513 2579.25 174873.91 67.80
OCCT-97530HM-OT SESSION BY OT ASST 39 140.00 7604.80 54.32
PHY-97110-PT SESSION BY LICENSED PT 665 3279.75 222230.42 67.76
PHY-97110HM-PT SESSION BY PT ASST 46 222.25 12072.58 54.32
SHIN-T1027SC-INITIAL SHINE SERVICES, INDIVIDUAL 5 11.00 550.00 50.00
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 944 4593.96 311204.58 67.74
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 12 29.50 1602.44 54.32
SPL-92508-GROUP SPL SESSION PER CHILD 7 14.00 184.80 13.20
Subtotal (Total Children Is Unduplicated) 3185 23625.2 1367104.57 57.87
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Total 53873.96 2611472.56 48.47
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Number of Children (Unduplicated) With at Least One Service 9022
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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 776 509.25 18842.25 0.00
P 4 5.00 222.00 0.00
D 161 129.00 4786.00 0.00
S 416 328.25 12145.25 0.00
H 6 7.50 458.25 0.00
T 1 0.50 18.50 0.00
564 1301.25 78232.32 0.00
Other 2431 1554.00 63207.66 0.00
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Total 4359 3834.75 177912.23 0.00
Center 02
Flag Claims Units Chgs Paid
-------------------------------------------------
R 10 6.50 240.50 0.00
U 0 0.00 0.00 0.00
B 727 1033.00 38156.25 0.00
P 0 5.00 222.00 0.00
D 0 129.00 4786.00 0.00
S 0 328.25 12145.25 0.00
H 0 7.50 458.25 0.00
T 0 0.50 18.50 0.00
116 1461.00 87260.57 0.00
Other 0 1554.00 63207.66 0.00
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Total 853 4524.75 206494.98 0.00
Center 03
Flag Claims Units Chgs Paid
-------------------------------------------------
R 6 10.00 370.00 0.00
U 0 0.00 0.00 0.00
B 454 1402.50 53755.50 9.25
P 854 708.50 26842.50 26620.50
D 0 129.00 4786.00 0.00
S 1 328.75 12163.75 0.00
H 1 7.75 467.50 9.25
T 0 0.50 18.50 0.00
39 1490.00 88390.57 0.00
Other 65 1618.50 64185.29 18.50
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Total 1420 5695.50 250979.61 26657.50
Center 04
Flag Claims Units Chgs Paid
-------------------------------------------------
R 8 22.75 841.75 0.00
U 0 0.00 0.00 0.00
B 2683 3949.00 151575.75 9.25
P 997 1581.25 60261.75 59688.06
D 2 130.75 4863.75 27.75
S 0 328.75 12163.75 0.00
H 721 2366.75 120231.12 119497.67
T 0 0.50 18.50 0.00
258 1997.50 129221.45 0.00
Other 0 1618.50 64185.29 18.50
-------------------------------------------------
Total 4669 11995.75 543363.11 179241.23
Center 05
Flag Claims Units Chgs Paid
-------------------------------------------------
R 13 35.75 1782.87 0.00
U 0 0.00 0.00 0.00
B 1864 4921.25 187644.00 9.25
P 0 1581.25 60261.75 59688.06
D 0 130.75 4863.75 27.75
S 0 328.75 12163.75 0.00
H 0 2366.75 120231.12 119497.67
T 0 0.50 18.50 0.00
1258 3110.25 193367.47 0.00
Other 0 1618.50 64185.29 18.50
-------------------------------------------------
Total 3135 14093.75 644518.50 179241.23
Center 06
Flag Claims Units Chgs Paid
-------------------------------------------------
R 0 35.75 1782.87 0.00
U 0 0.00 0.00 0.00
B 2191 6357.50 240763.50 92.50
P 0 1581.25 60261.75 59688.06
D 0 130.75 4863.75 27.75
S 0 328.75 12163.75 0.00
H 0 2366.75 120231.12 119497.67
T 0 0.50 18.50 0.00
3150 5792.75 355391.45 0.00
Other 0 1618.50 64185.29 18.50
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Total 5341 18212.50 859661.98 179324.48
Center 07
Flag Claims Units Chgs Paid
-------------------------------------------------
R 1 36.25 1801.37 0.00
U 0 0.00 0.00 0.00
B 1964 7751.75 296763.75 92.50
P 1140 2422.75 96637.00 96048.06
D 1 131.25 4882.25 27.75
S 149 441.50 16890.50 0.00
H 0 2366.75 120231.12 119497.67
T 0 0.50 18.50 0.00
652 7454.25 441928.69 0.00
Other 0 1618.50 64185.29 18.50
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Total 3907 22223.50 1043338.47 215684.48
Center 09
Flag Claims Units Chgs Paid
-------------------------------------------------
R 5 43.25 2173.37 0.00
U 0 0.00 0.00 0.00
B 553 8301.25 326130.34 120.25
P 2515 4600.00 192305.91 191616.97
D 0 131.25 4882.25 27.75
S 0 441.50 16890.50 0.00
H 1 2367.50 120258.87 119525.42
T 0 0.50 18.50 0.00
783 9624.25 576782.70 0.00
Other 0 1618.50 64185.29 18.50
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Total 3857 27128.00 1303627.73 311308.89
Center 10
Flag Claims Units Chgs Paid
-------------------------------------------------
R 5 45.00 2238.12 0.00
U 0 0.00 0.00 0.00
B 6136 12095.00 467188.09 120.25
P 485 5311.25 241987.66 241339.47
D 16 140.50 5224.50 370.00
S 156 536.50 20405.50 0.00
H 0 2367.50 120258.87 119525.42
T 0 0.50 18.50 0.00
802 11265.75 674515.94 0.00
Other 0 1618.50 64185.29 18.50
-------------------------------------------------
Total 7600 33380.50 1596022.47 361373.64
Center 51
Flag Claims Units Chgs Paid
-------------------------------------------------
R 2 47.00 2388.12 0.00
U 0 0.00 0.00 0.00
B 2983 14152.50 544860.89 120.25
P 0 5311.25 241987.66 241339.47
D 0 140.50 5224.50 370.00
S 0 536.50 20405.50 0.00
H 0 2367.50 120258.87 119525.42
T 0 0.50 18.50 0.00
885 13469.50 807456.76 0.00
Other 0 1618.50 64185.29 18.50
-------------------------------------------------
Total 3870 37643.75 1806786.09 361373.64
Center 52
Flag Claims Units Chgs Paid
-------------------------------------------------
R 8 55.00 2922.46 0.00
U 0 0.00 0.00 0.00
B 1257 14937.00 577742.56 129.50
P 756 5792.25 263102.87 262454.68
D 0 140.50 5224.50 370.00
S 3 546.00 20757.00 0.00
H 0 2367.50 120258.87 119525.42
T 0 0.50 18.50 0.00
550 14722.46 887945.01 0.00
Other 0 1618.50 64185.29 18.50
-------------------------------------------------
Total 2574 40179.71 1942157.06 382498.10
Center 53
Flag Claims Units Chgs Paid
-------------------------------------------------
R 121 191.50 7972.96 9.25
U 0 0.00 0.00 0.00
B 63 14993.25 579940.81 274.75
P 1160 6927.25 319684.62 318995.68
D 298 404.00 17340.89 370.00
S 4 551.00 21025.25 0.00
H 0 2367.50 120258.87 119525.42
T 0 0.50 18.50 0.00
1455 16092.96 959487.98 571.52
Other 0 1618.50 64185.29 18.50
-------------------------------------------------
Total 3101 43146.46 2089915.17 439765.12
Center 54
Flag Claims Units Chgs Paid
-------------------------------------------------
R 15 202.00 8352.21 9.25
U 0 0.00 0.00 0.00
B 949 15563.25 600994.81 274.75
P 1974 8232.25 367582.62 404147.76
D 2 404.50 17359.39 370.00
S 0 551.00 21025.25 0.00
H 0 2367.50 120258.87 119525.42
T 0 0.50 18.50 0.00
1067 18022.21 1071018.88 571.52
Other 0 1618.50 64185.29 18.50
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Total 4007 46961.71 2270795.82 524917.20
Center 55
Flag Claims Units Chgs Paid
-------------------------------------------------
R 30 240.25 9767.46 9.25
U 0 0.00 0.00 0.00
B 11 15578.25 602062.81 274.75
P 856 9047.75 398698.37 435263.51
D 0 404.50 17359.39 370.00
S 6 558.25 21293.50 0.00
H 0 2367.50 120258.87 119525.42
T 0 0.50 18.50 0.00
1461 19187.21 1146188.90 571.52
Other 0 1618.50 64185.29 18.50
-------------------------------------------------
Total 2364 49002.71 2379833.09 556032.95
Center 57
Flag Claims Units Chgs Paid
-------------------------------------------------
R 126 381.25 14984.46 9.25
U 0 0.00 0.00 0.00
B 1066 16623.50 640718.56 274.75
P 627 9635.25 420435.87 457000.91
D 10 415.25 17757.14 370.00
S 8 579.50 22339.75 1000.00
H 0 2367.50 120258.87 119525.42
T 13 42.00 2155.08 2136.58
1209 22210.71 1308619.04 117000.79
Other 1 1619.00 64203.79 18.50
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Total 3060 53873.96 2611472.56 697336.20