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: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 9642 29328.0 1083871.50 36.96
Subtotal (Total Children Is Unduplicated) 9642 29328.0 1083871.50 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 3 3.00 48.90 16.30
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 76 76.00 671.08 8.83
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 66 66.00 712.80 10.80
AUDE-92568-ACOUSTIC REFLEX TESTING (MEMR) 7 7.00 59.08 8.44
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 76 76.00 1656.04 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 81 111.50 8343.00 74.83
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 33 48.00 3600.00 75.00
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 39 50.00 3750.00 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 64 90.50 6750.00 74.59
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 98 131.00 7270.50 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 768 1058.00 79246.00 74.90
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 298 484.00 36262.50 74.92
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 351 497.00 37211.00 74.87
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 805 1161.50 64347.25 55.40
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 583 956.00 71626.50 74.92
MED-99202-OUTPATIENT VISIT, NEW, 20 MINS 3 3.00 81.66 27.22
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 73 73.00 13360.50 183.02
MED-99204-OUTPATIENT VISIT, NEW, 45 MINS 12 12.00 1340.43 111.70
MED-99205-OUTPATIENT VISIT, NEW, 60 MINS 6 6.00 436.68 72.78
MED-99212-OUTPATIENT VISIT, EST, 10 MINS 2 2.00 36.34 18.17
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 38 38.00 3990.00 105.00
MED-99214-OUTPATIENT VISIT, EST, 25 MINS 2 2.00 194.50 97.25
MED-99215-OUTPATIENT VISIT, EST, 40 MINS 4 4.00 200.60 50.15
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 25 25.00 1212.50 48.50
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 45 47.00 2279.50 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 116 119.00 5950.00 50.00
SPCH-92506-SPEECH EVAL BY LICENSED SLP 99 99.00 4801.50 48.50
Subtotal (Total Children Is Unduplicated) 2132 5348.50 360265.62 67.36
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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 1976 12703.5 635175.00 50.00
HERN-T1027SC-EI HEARING SERVICES AFTER SHINE 4 14.00 700.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 514 2580.25 174941.79 67.80
OCCT-97530HM-OT SESSION BY OT ASST 39 140.00 7604.80 54.32
PHY-97110-PT SESSION BY LICENSED PT 667 3285.25 222603.76 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 948 4619.46 312935.52 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) 3200 23683.2 1370576.73 57.87
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Total 58359.71 2814713.85 48.23
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Number of Children (Unduplicated) With at Least One Service 10185
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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 911 636.25 23541.25 0.00
P 4 5.00 222.00 0.00
D 204 170.75 6330.75 0.00
S 504 406.75 15049.75 0.00
H 7 8.50 533.25 0.00
T 1 0.50 18.50 0.00
605 1342.50 80588.41 0.00
Other 2731 1823.75 75258.16 0.00
-------------------------------------------------
Total 4967 4394.00 201542.07 0.00
Center 02
Flag Claims Units Chgs Paid
-------------------------------------------------
R 16 13.25 490.25 0.00
U 0 0.00 0.00 0.00
B 777 1207.75 44622.00 0.00
P 0 5.00 222.00 0.00
D 0 170.75 6330.75 0.00
S 0 406.75 15049.75 0.00
H 0 8.50 533.25 0.00
T 0 0.50 18.50 0.00
136 1537.50 91553.16 0.00
Other 0 1823.75 75258.16 0.00
-------------------------------------------------
Total 929 5173.75 234077.82 0.00
Center 03
Flag Claims Units Chgs Paid
-------------------------------------------------
R 11 18.75 693.75 0.00
U 0 0.00 0.00 0.00
B 540 1659.25 63718.50 9.25
P 966 806.50 30798.75 30563.75
D 0 170.75 6330.75 0.00
S 1 407.25 15068.25 0.00
H 1 8.75 542.50 9.25
T 0 0.50 18.50 0.00
41 1568.00 92738.66 0.00
Other 73 1896.25 76354.75 18.50
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Total 1633 6536.00 286264.41 30600.75
Center 04
Flag Claims Units Chgs Paid
-------------------------------------------------
R 12 41.25 1526.25 0.00
U 0 0.00 0.00 0.00
B 2983 4546.50 175441.25 9.25
P 1105 1787.75 68365.00 67778.31
D 2 172.50 6408.50 27.75
S 0 407.25 15068.25 0.00
H 723 2375.75 120706.12 119897.67
T 0 0.50 18.50 0.00
277 2095.50 136597.54 0.00
Other 0 1896.25 76354.75 18.50
-------------------------------------------------
Total 5102 13323.25 600486.16 187731.48
Center 05
Flag Claims Units Chgs Paid
-------------------------------------------------
R 20 61.25 2890.45 0.00
U 0 0.00 0.00 0.00
B 2209 5708.25 218521.00 9.25
P 0 1787.75 68365.00 67778.31
D 0 172.50 6408.50 27.75
S 0 407.25 15068.25 0.00
H 0 2375.75 120706.12 119897.67
T 0 0.50 18.50 0.00
1276 3224.25 201844.59 0.00
Other 0 1896.25 76354.75 18.50
-------------------------------------------------
Total 3505 15633.75 710177.16 187731.48
Center 06
Flag Claims Units Chgs Paid
-------------------------------------------------
R 0 61.25 2890.45 0.00
U 0 0.00 0.00 0.00
B 2623 7421.00 281871.00 92.50
P 0 1787.75 68365.00 67778.31
D 0 172.50 6408.50 27.75
S 0 407.25 15068.25 0.00
H 0 2375.75 120706.12 119897.67
T 0 0.50 18.50 0.00
3249 6004.00 369610.52 0.00
Other 0 1896.25 76354.75 18.50
-------------------------------------------------
Total 5872 20126.25 941293.09 187814.73
Center 07
Flag Claims Units Chgs Paid
-------------------------------------------------
R 1 61.75 2908.95 0.00
U 0 0.00 0.00 0.00
B 2099 8950.75 343820.50 92.50
P 1227 2723.00 109091.00 108489.06
D 2 173.50 6445.50 27.75
S 158 530.50 20331.50 0.00
H 0 2375.75 120706.12 119897.67
T 0 0.50 18.50 0.00
660 7679.50 457012.51 0.00
Other 0 1896.25 76354.75 18.50
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Total 4147 24391.50 1136689.33 228525.48
Center 09
Flag Claims Units Chgs Paid
-------------------------------------------------
R 7 70.25 3336.45 0.00
U 0 0.00 0.00 0.00
B 582 9539.00 375462.84 120.25
P 2830 5300.00 225251.41 224549.47
D 0 173.50 6445.50 27.75
S 0 530.50 20331.50 0.00
H 1 2376.50 120733.87 119925.42
T 0 0.50 18.50 0.00
784 9851.50 592016.52 0.00
Other 0 1896.25 76354.75 18.50
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Total 4204 29738.00 1419951.34 344641.39
Center 10
Flag Claims Units Chgs Paid
-------------------------------------------------
R 5 72.00 3401.20 0.00
U 0 0.00 0.00 0.00
B 6561 13719.50 531208.34 120.25
P 614 6199.75 288466.16 287804.97
D 18 183.75 6824.75 407.00
S 168 634.25 24170.25 0.00
H 0 2376.50 120733.87 119925.42
T 0 0.50 18.50 0.00
802 11493.00 689749.76 0.00
Other 0 1896.25 76354.75 18.50
-------------------------------------------------
Total 8168 36575.50 1740927.58 408276.14
Center 51
Flag Claims Units Chgs Paid
-------------------------------------------------
R 2 74.00 3551.20 0.00
U 0 0.00 0.00 0.00
B 3196 15970.50 616154.64 120.25
P 0 6199.75 288466.16 287804.97
D 0 183.75 6824.75 407.00
S 0 634.25 24170.25 0.00
H 0 2376.50 120733.87 119925.42
T 0 0.50 18.50 0.00
917 13738.25 825567.51 0.00
Other 0 1896.25 76354.75 18.50
-------------------------------------------------
Total 4115 41073.75 1961841.63 408276.14
Center 52
Flag Claims Units Chgs Paid
-------------------------------------------------
R 8 82.00 4085.54 0.00
U 0 0.00 0.00 0.00
B 1351 16822.00 651581.56 129.50
P 833 6742.75 312456.87 311795.68
D 0 183.75 6824.75 407.00
S 3 643.75 24521.75 0.00
H 0 2376.50 120733.87 119925.42
T 0 0.50 18.50 0.00
562 15007.71 907190.26 0.00
Other 0 1896.25 76354.75 18.50
-------------------------------------------------
Total 2757 43755.21 2103767.85 432276.10
Center 53
Flag Claims Units Chgs Paid
-------------------------------------------------
R 136 239.75 9922.29 9.25
U 0 0.00 0.00 0.00
B 64 16879.25 653816.81 274.75
P 1257 8004.25 376291.87 375589.43
D 344 498.00 21150.64 407.00
S 4 648.75 24790.00 0.00
H 0 2376.50 120733.87 119925.42
T 0 0.50 18.50 0.00
1455 16378.21 978733.23 571.52
Other 0 1896.25 76354.75 18.50
-------------------------------------------------
Total 3260 46921.46 2261811.96 496795.87
Center 54
Flag Claims Units Chgs Paid
-------------------------------------------------
R 15 250.25 10301.54 9.25
U 0 0.00 0.00 0.00
B 1143 17585.00 680016.31 274.75
P 2271 9497.50 431223.37 467775.01
D 2 498.50 21169.14 407.00
S 0 648.75 24790.00 0.00
H 0 2376.50 120733.87 119925.42
T 0 0.50 18.50 0.00
1117 18363.96 1094079.63 571.52
Other 0 1896.25 76354.75 18.50
-------------------------------------------------
Total 4548 51117.21 2458687.11 588981.45
Center 55
Flag Claims Units Chgs Paid
-------------------------------------------------
R 31 289.00 11735.29 9.25
U 0 0.00 0.00 0.00
B 14 17604.50 681421.81 274.75
P 976 10458.50 468083.62 504635.26
D 0 498.50 21169.14 407.00
S 11 663.00 25317.25 0.00
H 0 2376.50 120733.87 119925.42
T 0 0.50 18.50 0.00
1490 19582.46 1172998.90 571.52
Other 1 1896.75 76373.25 18.50
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Total 2523 53369.71 2577851.63 625841.70
Center 57
Flag Claims Units Chgs Paid
-------------------------------------------------
R 136 446.50 17562.79 9.25
U 0 0.00 0.00 0.00
B 1092 18682.75 721298.56 274.75
P 652 11081.00 491116.12 527667.66
D 10 509.25 21566.89 407.00
S 9 684.50 26372.75 1000.00
H 0 2376.50 120733.87 119925.42
T 13 42.00 2155.08 2136.58
1241 22639.96 1337516.04 117000.79
Other 1 1897.25 76391.75 18.50
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Total 3154 58359.71 2814713.85 768439.95