CMS/EIP Fiscal Report Statewide
Services beginning 01/01/2009 ending 03/31/2009 Date of Report:05/18/2009 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 10131 32267.3 1192624.25 36.96
Subtotal (Total Children Is Unduplicated) 10131 32267.3 1192624.25 36.96
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Screening, Eval, and Assessment,Class #02
AUDE-92552-PURE TONE AUDIOMETRY -AIR ONLY 2 2.00 21.24 10.62
AUDE-92553-PURE TONE AUDIOMETRY AIR & BONE 3 3.00 48.90 16.30
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 97 98.00 865.34 8.83
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 81 85.00 918.00 10.80
AUDE-92568-ACOUSTIC REFLEX TESTING (MEMR) 5 5.00 42.20 8.44
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 97 100.00 2179.00 21.79
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 9 9.00 254.52 28.28
AUDE-92588-OTOACOUSTIC EMISSIONS (COMP) 11 11.00 349.91 31.81
AUDE-V5010-ASSESSMENT FOR HEARING AID 1 1.00 46.80 46.80
BEHV-H0031HO-COMP BEHAVIORAL HEALTH ASSESSMENT 2 2.00 250.00 125.00
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 83 112.50 8437.50 75.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 35 54.50 4087.50 75.00
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 33 40.50 3037.50 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 70 98.50 7387.50 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 103 145.50 8064.25 55.42
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 845 1149.50 85974.00 74.79
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 330 530.00 39584.50 74.69
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 341 468.00 34866.00 74.50
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 1032 1502.50 83277.75 55.43
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 673 1083.50 81150.00 74.90
MED-99202-OUTPATIENT VISIT, NEW, 20 MINS 3 3.00 189.44 63.15
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 117 118.00 20963.00 177.65
MED-99204-OUTPATIENT VISIT, NEW, 45 MINS 8 8.00 1111.35 138.92
MED-99205-OUTPATIENT VISIT, NEW, 60 MINS 11 11.00 800.58 72.78
MED-99212-OUTPATIENT VISIT, EST, 10 MINS 1 1.00 18.17 18.17
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 42 42.00 4410.00 105.00
MED-99214-OUTPATIENT VISIT, EST, 25 MINS 3 3.00 480.00 160.00
MED-99215-OUTPATIENT VISIT, EST, 40 MINS 6 6.00 300.90 50.15
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 44 45.00 2182.50 48.50
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 57 61.00 2958.50 48.50
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 37 37.00 1794.50 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 58 64.00 3104.00 48.50
SCREEN-T1023-INTERDISCIPLINARY SCREENING 88 89.00 4450.00 50.00
SPCH-92506-SPEECH EVAL BY LICENSED SLP 125 126.00 6111.00 48.50
Subtotal (Total Children Is Unduplicated) 2399 6115.00 409716.35 67.00
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 2 5.00 1096.80 219.36
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 17 61.00 1525.00 25.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 2188 13906.5 695325.00 50.00
HERN-T1027SC-EI HEARING SERVICES AFTER SHINE 4 21.00 1050.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 576 2877.50 194752.45 67.68
OCCT-97530HM-OT SESSION BY OT ASST 48 291.00 15807.12 54.32
PHY-97110-PT SESSION BY LICENSED PT 694 3590.25 243628.20 67.86
PHY-97110HM-PT SESSION BY PT ASST 46 198.00 10755.36 54.32
SENS-V5264-EARMOLD 1 2.00 37.44 18.72
SHIN-T1027SC-INITIAL SHINE SERVICES, INDIVIDUAL 5 9.50 475.00 50.00
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 980 4665.84 316391.06 67.81
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 5 11.00 597.52 54.32
SPL-92508-GROUP SPL SESSION PER CHILD 25 72.00 950.40 13.20
Subtotal (Total Children Is Unduplicated) 3446 25710.6 1482391.35 57.66
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Total 64092.84 3084731.95 48.13
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Number of Children (Unduplicated) With at Least One Service 10698
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Center 01
Flag Claims Units Chgs Paid
-------------------------------------------------
R 8 5.00 185.00 0.00
U 0 0.00 0.00 0.00
B 3248 2380.75 88838.25 0.00
P 350 243.25 9000.25 9000.20
D 4 1.25 46.25 0.00
S 1028 804.00 29748.00 0.00
H 0 0.00 0.00 0.00
T 1 1.25 46.25 0.00
484 960.75 57916.32 0.00
Other 291 333.75 20126.88 0.00
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Total 5414 4730.00 205907.20 9000.20
Center 02
Flag Claims Units Chgs Paid
-------------------------------------------------
R 3 5.75 212.75 0.00
U 0 0.00 0.00 0.00
B 816 3033.25 112842.00 0.00
P 0 243.25 9000.25 9000.20
D 0 1.25 46.25 0.00
S 0 804.00 29748.00 0.00
H 0 0.00 0.00 0.00
T 0 1.25 46.25 0.00
170 1190.00 72643.82 0.00
Other 1 334.50 20154.63 0.00
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Total 990 5613.25 244693.95 9000.20
Center 03
Flag Claims Units Chgs Paid
-------------------------------------------------
R 4 8.25 333.00 0.00
U 0 0.00 0.00 0.00
B 660 3502.50 131672.25 37.00
P 1339 1274.25 49357.25 49357.20
D 0 1.25 46.25 0.00
S 0 804.00 29748.00 0.00
H 0 0.00 0.00 0.00
T 0 1.25 46.25 0.00
195 1347.00 79117.82 0.00
Other 98 433.75 21720.44 0.00
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Total 2296 7372.25 312041.26 49394.20
Center 04
Flag Claims Units Chgs Paid
-------------------------------------------------
R 2 10.25 420.00 0.00
U 0 0.00 0.00 0.00
B 3421 6898.50 265663.25 37.00
P 1182 2398.00 93435.02 92754.03
D 0 1.25 46.25 0.00
S 0 804.00 29748.00 0.00
H 778 2488.34 127679.54 127921.86
T 0 1.25 46.25 0.00
335 1914.00 129685.60 0.00
Other 0 433.75 21720.44 0.00
-------------------------------------------------
Total 5718 14949.34 668444.35 220712.89
Center 05
Flag Claims Units Chgs Paid
-------------------------------------------------
R 58 45.75 1733.50 0.00
U 0 0.00 0.00 0.00
B 2278 8144.50 312501.31 37.00
P 1 2399.00 93510.02 92829.03
D 0 1.25 46.25 0.00
S 0 804.00 29748.00 0.00
H 0 2488.34 127679.54 127921.86
T 0 1.25 46.25 0.00
1531 3094.25 199887.24 0.00
Other 0 433.75 21720.44 0.00
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Total 3868 17412.09 786872.55 220787.89
Center 06
Flag Claims Units Chgs Paid
-------------------------------------------------
R 8 49.75 1881.50 111.00
U 0 0.00 0.00 0.00
B 2096 9602.50 366447.31 37.00
P 877 2977.00 114896.02 114215.03
D 0 1.25 46.25 0.00
S 0 804.00 29748.00 0.00
H 0 2488.34 127679.54 127921.86
T 1 1.50 55.50 0.00
3513 5990.25 368369.91 0.00
Other 0 433.75 21720.44 0.00
-------------------------------------------------
Total 6495 22348.34 1030844.47 242284.89
Center 07
Flag Claims Units Chgs Paid
-------------------------------------------------
R 21 76.50 3384.25 111.00
U 0 0.00 0.00 0.00
B 3707 12187.75 470841.62 37.00
P 265 3270.00 131053.02 130372.03
D 0 1.25 46.25 0.00
S 201 916.00 33892.00 0.00
H 0 2488.34 127679.54 127921.86
T 0 1.50 55.50 0.00
730 7909.75 469394.46 0.00
Other 0 433.75 21720.44 0.00
-------------------------------------------------
Total 4924 27284.84 1258067.08 258441.89
Center 09
Flag Claims Units Chgs Paid
-------------------------------------------------
R 35 99.25 4226.00 111.00
U 0 0.00 0.00 0.00
B 653 12734.00 498192.65 466.50
P 2755 5677.00 241691.16 323896.92
D 0 1.25 46.25 0.00
S 0 916.00 33892.00 0.00
H 0 2488.34 127679.54 127921.86
T 0 1.50 55.50 0.00
1040 10667.25 639887.19 0.00
Other 6 435.75 21794.44 0.00
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Total 4489 33020.34 1567464.73 452396.28
Center 10
Flag Claims Units Chgs Paid
-------------------------------------------------
R 66 147.75 6020.50 111.00
U 0 0.00 0.00 0.00
B 4520 15844.00 618611.65 549.75
P 2617 7687.50 338112.41 420318.17
D 4 4.25 157.25 111.00
S 289 1085.50 41005.25 0.00
H 0 2488.34 127679.54 127921.86
T 0 1.50 55.50 0.00
743 12417.50 741993.09 0.00
Other 0 435.75 21794.44 0.00
-------------------------------------------------
Total 8239 40112.09 1895429.63 549011.78
Center 51
Flag Claims Units Chgs Paid
-------------------------------------------------
R 2 148.75 6057.50 111.00
U 0 0.00 0.00 0.00
B 3387 18197.25 708432.37 549.75
P 1 7687.75 338121.66 420318.17
D 0 4.25 157.25 111.00
S 0 1085.50 41005.25 0.00
H 0 2488.34 127679.54 127921.86
T 0 1.50 55.50 0.00
1025 14859.75 889335.32 0.00
Other 0 435.75 21794.44 0.00
-------------------------------------------------
Total 4415 44908.84 2132638.83 549011.78
Center 52
Flag Claims Units Chgs Paid
-------------------------------------------------
R 3 153.75 6432.50 111.00
U 0 0.00 0.00 0.00
B 2059 19548.75 767085.44 549.75
P 0 7687.75 338121.66 420318.17
D 0 4.25 157.25 111.00
S 24 1106.00 42048.75 0.00
H 0 2488.34 127679.54 127921.86
T 0 1.50 55.50 0.00
563 16127.75 969086.82 0.00
Other 0 435.75 21794.44 0.00
-------------------------------------------------
Total 2649 47553.84 2272461.90 549011.78
Center 53
Flag Claims Units Chgs Paid
-------------------------------------------------
R 27 177.25 7530.00 111.00
U 0 0.00 0.00 0.00
B 42 19593.00 769230.69 1016.25
P 2014 9627.25 428065.91 510237.42
D 52 85.25 5949.51 111.00
S 0 1106.00 42048.75 0.00
H 0 2488.34 127679.54 127921.86
T 0 1.50 55.50 0.00
1583 17622.75 1045835.44 50.00
Other 1 437.75 21891.44 0.00
-------------------------------------------------
Total 3719 51139.09 2448286.78 639447.53
Center 54
Flag Claims Units Chgs Paid
-------------------------------------------------
R 3 179.00 7594.75 111.00
U 0 0.00 0.00 0.00
B 1241 20651.25 819828.69 1016.25
P 2875 11525.75 498435.66 580607.17
D 0 85.25 5949.51 111.00
S 1 1106.50 42067.25 0.00
H 0 2488.34 127679.54 127921.86
T 0 1.50 55.50 0.00
777 19612.00 1162552.50 50.00
Other 2 439.25 21946.94 0.00
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Total 4899 56088.84 2686110.34 709817.28
Center 55
Flag Claims Units Chgs Paid
-------------------------------------------------
R 0 179.00 7594.75 111.00
U 0 0.00 0.00 0.00
B 9 20660.50 820227.94 1016.25
P 1070 12558.50 538496.91 620705.92
D 0 85.25 5949.51 111.00
S 17 1124.75 42781.00 0.00
H 0 2488.34 127679.54 127921.86
T 0 1.50 55.50 0.00
1919 21124.75 1258450.86 50.00
Other 0 439.25 21946.94 0.00
-------------------------------------------------
Total 3015 58661.84 2823182.95 749916.03
Center 57
Flag Claims Units Chgs Paid
-------------------------------------------------
R 259 448.00 18148.25 111.00
U 0 0.00 0.00 0.00
B 385 21057.50 837330.44 1016.25
P 1353 14022.75 596039.66 678248.67
D 0 85.25 5949.51 111.00
S 0 1124.75 42781.00 0.00
H 0 2488.34 127679.54 127921.86
T 9 25.00 1237.94 1182.44
1181 24402.00 1433618.67 132612.99
Other 0 439.25 21946.94 0.00
-------------------------------------------------
Total 3187 64092.84 3084731.95 941204.21