CMS/EIP Fiscal Report Statewide
Services beginning 04/01/2009 ending 06/30/2009 Date of Report:08/25/2009 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 9718 31494.5 1164310.50 36.97
Subtotal (Total Children Is Unduplicated) 9718 31494.5 1164310.50 36.97
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Screening, Eval, and Assessment,Class #02
AUDE-92552-PURE TONE AUDIOMETRY -AIR ONLY 3 3.00 31.86 10.62
AUDE-92553-PURE TONE AUDIOMETRY AIR & BONE 2 2.00 32.60 16.30
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 94 96.00 847.68 8.83
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 79 83.00 895.98 10.79
AUDE-92568-ACOUSTIC REFLEX TESTING (MEMR) 8 8.00 67.52 8.44
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 100 103.00 2244.37 21.79
AUDE-92585-AUD EVOKED RESPONSE (DIAG) 3 3.00 163.14 54.38
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 6 6.00 169.68 28.28
AUDE-92588-OTOACOUSTIC EMISSIONS (COMP) 19 19.00 604.39 31.81
BEHV-H0031HO-COMP BEHAVIORAL HEALTH ASSESSMENT 1 1.00 125.00 125.00
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 82 115.00 8625.00 75.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 22 33.50 2512.50 75.00
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 29 35.50 2636.00 74.25
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 37 60.50 4537.50 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 70 92.50 5122.75 55.38
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 737 1069.00 80020.50 74.86
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 274 447.50 33542.50 74.96
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 285 368.50 27584.50 74.86
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 845 1313.50 72867.50 55.48
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 545 893.50 66937.50 74.92
MED-99202-OUTPATIENT VISIT, NEW, 20 MINS 1 1.00 27.22 27.22
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 78 78.00 14285.50 183.15
MED-99204-OUTPATIENT VISIT, NEW, 45 MINS 13 13.00 1397.70 107.52
MED-99205-OUTPATIENT VISIT, NEW, 60 MINS 1 1.00 72.78 72.78
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 22 22.00 2310.00 105.00
MED-99215-OUTPATIENT VISIT, EST, 40 MINS 4 4.00 200.60 50.15
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 31 38.00 1843.00 48.50
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 66 67.00 3249.50 48.50
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 28 28.00 1358.00 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 63 64.00 3104.00 48.50
SCREEN-T1023-INTERDISCIPLINARY SCREENING 58 58.00 2900.00 50.00
SPCH-92506-SPEECH EVAL BY LICENSED SLP 131 133.00 6450.50 48.50
Subtotal (Total Children Is Unduplicated) 2028 5260.00 346767.27 65.93
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 6 13.00 4791.52 368.58
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 20 62.00 1550.00 25.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 2535 17863.3 893002.50 49.99
HERN-T1027SC-EI HEARING SERVICES AFTER SHINE 3 12.00 600.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 695 3711.00 251882.34 67.87
OCCT-97530HM-OT SESSION BY OT ASST 64 342.25 18591.02 54.32
PHY-97110-PT SESSION BY LICENSED PT 819 4012.75 272103.23 67.81
PHY-97110HM-PT SESSION BY PT ASST 54 275.75 14978.74 54.32
SENS-V5264-EARMOLD 1 2.00 37.44 18.72
SHIN-T1027SC-INITIAL SHINE SERVICES, INDIVIDUAL 8 12.00 600.00 50.00
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 1232 5589.59 378979.41 67.80
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 13 26.25 1425.90 54.32
SPL-92508-GROUP SPL SESSION PER CHILD 17 43.50 574.20 13.20
VISN-T1027SC-EI VISION SERVICES, INDIVIDUAL 1 86.00 4300.00 50.00
Subtotal (Total Children Is Unduplicated) 4046 32051.3 1843416.30 57.51
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Total 68805.84 3354494.07 48.75
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Number of Children (Unduplicated) With at Least One Service 10388
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Center 01
Flag Claims Units Chgs Paid
-------------------------------------------------
R 70 82.50 5203.25 0.00
U 0 0.00 0.00 0.00
B 2036 1410.75 54400.75 0.00
P 1319 950.25 36181.00 36180.50
D 72 84.50 5937.50 0.00
S 1496 1146.25 42411.25 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
567 1163.75 63265.82 0.00
Other 206 291.00 17456.83 0.00
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Total 5766 5129.00 224856.40 36180.50
Center 02
Flag Claims Units Chgs Paid
-------------------------------------------------
R 12 91.75 5545.50 0.00
U 0 0.00 0.00 0.00
B 932 2165.75 82197.00 0.00
P 0 950.25 36181.00 36180.50
D 0 84.50 5937.50 0.00
S 0 1146.25 42411.25 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
98 1318.00 73361.07 0.00
Other 0 291.00 17456.83 0.00
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Total 1042 6047.50 263090.15 36180.50
Center 03
Flag Claims Units Chgs Paid
-------------------------------------------------
R 3 92.50 5573.25 0.00
U 0 0.00 0.00 0.00
B 70 2208.25 83823.25 0.00
P 1919 2361.00 92724.25 99858.25
D 0 84.50 5937.50 0.00
S 0 1146.25 42411.25 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
298 1530.25 81214.32 0.00
Other 84 376.00 18841.29 27.75
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Total 2374 7798.75 330525.11 99886.00
Center 04
Flag Claims Units Chgs Paid
-------------------------------------------------
R 25 114.00 6368.75 0.00
U 0 0.00 0.00 0.00
B 1805 4023.75 158365.25 0.00
P 2314 4653.00 181798.09 185191.93
D 4 95.50 6510.80 569.70
S 0 1146.25 42411.25 0.00
H 1268 4225.00 217226.92 217568.26
T 0 0.00 0.00 0.00
219 1920.75 113592.72 450.00
Other 0 376.00 18841.29 27.75
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Total 5635 16554.25 745115.07 403807.64
Center 05
Flag Claims Units Chgs Paid
-------------------------------------------------
R 0 114.00 6368.75 0.00
U 0 0.00 0.00 0.00
B 2001 5080.00 197548.65 0.00
P 3 4655.00 181872.09 185219.68
D 0 95.50 6510.80 569.70
S 0 1146.25 42411.25 0.00
H 0 4225.00 217226.92 217568.26
T 1 2.25 83.25 0.00
1501 3162.00 184321.13 450.00
Other 0 376.00 18841.29 27.75
-------------------------------------------------
Total 3506 18856.00 855184.13 403835.39
Center 06
Flag Claims Units Chgs Paid
-------------------------------------------------
R 0 114.00 6368.75 0.00
U 0 0.00 0.00 0.00
B 1434 6126.25 236259.90 582.75
P 1376 5720.50 228857.59 232167.68
D 0 95.50 6510.80 569.70
S 0 1146.25 42411.25 0.00
H 0 4225.00 217226.92 217568.26
T 0 2.25 83.25 0.00
3689 6080.25 349014.13 450.00
Other 0 376.00 18841.29 27.75
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Total 6499 23886.00 1105573.88 451366.14
Center 07
Flag Claims Units Chgs Paid
-------------------------------------------------
R 21 124.50 6890.25 0.00
U 0 0.00 0.00 0.00
B 1136 6823.50 262791.15 582.75
P 3309 8003.00 324707.12 328017.21
D 0 95.50 6510.80 569.70
S 64 1181.25 43706.25 0.00
H 0 4225.00 217226.92 217568.26
T 0 2.25 83.25 0.00
1027 8912.50 504383.57 450.00
Other 0 376.00 18841.29 27.75
-------------------------------------------------
Total 5557 29743.50 1385140.60 547215.67
Center 09
Flag Claims Units Chgs Paid
-------------------------------------------------
R 6 132.25 7177.00 0.00
U 0 0.00 0.00 0.00
B 825 7568.50 297838.72 787.01
P 2887 10456.00 435040.64 438221.98
D 0 95.50 6510.80 569.70
S 0 1181.25 43706.25 0.00
H 0 4225.00 217226.92 217568.26
T 0 2.25 83.25 0.00
1175 12063.25 699530.94 601.51
Other 0 376.00 18841.29 27.75
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Total 4893 36100.00 1725955.81 657776.21
Center 10
Flag Claims Units Chgs Paid
-------------------------------------------------
R 18 141.25 7510.00 0.00
U 0 0.00 0.00 0.00
B 5437 11089.75 435607.47 787.01
P 1329 11586.75 493598.33 496745.73
D 0 95.50 6510.80 569.70
S 536 1550.50 57368.50 0.00
H 0 4225.00 217226.92 217568.26
T 0 2.25 83.25 0.00
1312 14751.00 862446.12 601.51
Other 0 376.00 18841.29 27.75
-------------------------------------------------
Total 8632 43818.00 2099192.68 716299.96
Center 51
Flag Claims Units Chgs Paid
-------------------------------------------------
R 4 143.00 7574.75 0.00
U 0 0.00 0.00 0.00
B 2983 13188.25 514581.07 787.01
P 0 11586.75 493598.33 496745.73
D 0 95.50 6510.80 569.70
S 0 1550.50 57368.50 0.00
H 0 4225.00 217226.92 217568.26
T 0 2.25 83.25 0.00
1161 17711.50 1042588.68 601.51
Other 1 377.50 18953.79 27.75
-------------------------------------------------
Total 4149 48880.25 2358486.09 716299.96
Center 52
Flag Claims Units Chgs Paid
-------------------------------------------------
R 0 143.00 7574.75 0.00
U 0 0.00 0.00 0.00
B 2181 14690.00 581202.36 787.01
P 0 11586.75 493598.33 496745.73
D 0 95.50 6510.80 569.70
S 18 1570.00 58379.25 0.00
H 0 4225.00 217226.92 217568.26
T 0 2.25 83.25 0.00
608 19093.25 1131181.17 601.51
Other 0 377.50 18953.79 27.75
-------------------------------------------------
Total 2807 51783.25 2514710.62 716299.96
Center 53
Flag Claims Units Chgs Paid
-------------------------------------------------
R 3 143.75 7602.50 0.00
U 0 0.00 0.00 0.00
B 9 14698.25 581583.11 787.01
P 2019 13540.25 586331.58 589478.98
D 43 140.75 8265.80 569.70
S 0 1570.00 58379.25 0.00
H 0 4225.00 217226.92 217568.26
T 0 2.25 83.25 0.00
1765 20782.75 1219297.21 601.51
Other 0 377.50 18953.79 27.75
-------------------------------------------------
Total 3839 55480.50 2697723.41 809033.21
Center 54
Flag Claims Units Chgs Paid
-------------------------------------------------
R 5 146.50 7704.25 0.00
U 0 0.00 0.00 0.00
B 94 14787.25 586371.37 787.01
P 3508 15931.00 681541.58 684679.73
D 0 140.75 8265.80 569.70
S 0 1570.00 58379.25 0.00
H 0 4225.00 217226.92 217568.26
T 1 2.50 92.50 0.00
771 22864.50 1341721.27 601.51
Other 0 377.50 18953.79 27.75
-------------------------------------------------
Total 4379 60045.00 2920256.73 904233.96
Center 55
Flag Claims Units Chgs Paid
-------------------------------------------------
R 5 151.25 7880.00 0.00
U 0 0.00 0.00 0.00
B 0 14787.25 586371.37 787.01
P 914 16829.75 716955.08 720093.23
D 1 141.75 8302.80 569.70
S 2 1572.25 58462.50 0.00
H 0 4225.00 217226.92 217568.26
T 0 2.50 92.50 0.00
2468 24692.84 1458094.53 601.51
Other 0 377.50 18953.79 27.75
-------------------------------------------------
Total 3390 62780.09 3072339.49 939647.46
Center 57
Flag Claims Units Chgs Paid
-------------------------------------------------
R 115 295.00 13368.25 0.00
U 0 0.00 0.00 0.00
B 436 15282.25 606621.37 787.01
P 1755 18684.25 790440.33 793578.48
D 0 141.75 8302.80 569.70
S 0 1572.25 58462.50 0.00
H 0 4225.00 217226.92 217568.26
T 11 36.50 1828.26 1735.76
1126 28191.34 1639289.85 164929.42
Other 0 377.50 18953.79 27.75
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Total 3443 68805.84 3354494.07 1179196.38