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: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 11005 35540.0 1313938.50 36.97
Subtotal (Total Children Is Unduplicated) 11005 35540.0 1313938.50 36.97
----------------------------------------------------------------------------------------------------------------
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 3 3.00 48.90 16.30
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 99 101.00 891.83 8.83
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 82 86.00 928.38 10.80
AUDE-92568-ACOUSTIC REFLEX TESTING (MEMR) 8 8.00 67.52 8.44
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 104 107.00 2331.53 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 94 128.50 9637.50 75.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 25 38.00 2850.00 75.00
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 36 43.50 3236.00 74.39
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 45 70.50 5287.50 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 83 110.50 6121.75 55.40
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 981 1388.00 103945.50 74.89
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 367 595.00 44605.00 74.97
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 394 500.00 37420.50 74.84
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 1155 1760.50 97676.00 55.48
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 731 1137.50 85237.50 74.93
MED-99202-OUTPATIENT VISIT, NEW, 20 MINS 1 1.00 27.22 27.22
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 90 90.00 16505.50 183.39
MED-99204-OUTPATIENT VISIT, NEW, 45 MINS 14 14.00 1454.97 103.93
MED-99205-OUTPATIENT VISIT, NEW, 60 MINS 7 7.00 509.46 72.78
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 22 22.00 2310.00 105.00
MED-99215-OUTPATIENT VISIT, EST, 40 MINS 6 6.00 300.90 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 67 68.00 3298.00 48.50
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 28 28.00 1358.00 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 65 66.00 3201.00 48.50
SCREEN-T1023-INTERDISCIPLINARY SCREENING 119 120.00 6000.00 50.00
SPCH-92506-SPEECH EVAL BY LICENSED SLP 132 134.00 6499.00 48.50
Subtotal (Total Children Is Unduplicated) 2631 6703.00 444686.53 66.34
----------------------------------------------------------------------------------------------------------------
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 2556 17973.3 898502.50 49.99
HERN-T1027SC-EI HEARING SERVICES AFTER SHINE 3 12.00 600.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 697 3718.50 252391.44 67.87
OCCT-97530HM-OT SESSION BY OT ASST 64 342.25 18591.02 54.32
PHY-97110-PT SESSION BY LICENSED PT 822 4026.75 273053.55 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 1234 5594.59 379318.81 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) 4070 32187.8 1850715.12 57.50
----------------------------------------------------------------------------------------------------------------
Total 74430.84 3609340.15 48.49
----------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 11702
----------------------------------------------------------------------------------------------------------------
Center 01
Flag Claims Units Chgs Paid
-------------------------------------------------
R 109 123.25 7777.00 0.00
U 0 0.00 0.00 0.00
B 2448 1728.50 66954.25 0.00
P 1568 1143.00 43760.25 43759.75
D 95 109.50 7773.50 0.00
S 1768 1384.00 51208.00 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
620 1233.00 66348.07 0.00
Other 213 301.00 18156.83 0.00
-------------------------------------------------
Total 6821 6022.25 261977.90 43759.75
Center 02
Flag Claims Units Chgs Paid
-------------------------------------------------
R 12 132.50 8119.25 0.00
U 0 0.00 0.00 0.00
B 1045 2594.00 98811.25 0.00
P 0 1143.00 43760.25 43759.75
D 0 109.50 7773.50 0.00
S 1 1385.25 51254.25 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
116 1417.75 78535.82 0.00
Other 0 301.00 18156.83 0.00
-------------------------------------------------
Total 1174 7083.00 306411.15 43759.75
Center 03
Flag Claims Units Chgs Paid
-------------------------------------------------
R 3 133.25 8147.00 0.00
U 0 0.00 0.00 0.00
B 77 2641.00 100604.00 0.00
P 2196 2793.75 110548.75 117682.75
D 0 109.50 7773.50 0.00
S 0 1385.25 51254.25 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
338 1664.00 87647.07 0.00
Other 94 396.00 19679.88 27.75
-------------------------------------------------
Total 2708 9122.75 385654.45 117710.50
Center 04
Flag Claims Units Chgs Paid
-------------------------------------------------
R 30 160.25 9146.00 0.00
U 0 0.00 0.00 0.00
B 2043 4699.75 186180.25 0.00
P 2550 5366.00 210879.84 213467.46
D 4 120.50 8346.80 569.70
S 0 1385.25 51254.25 0.00
H 1276 4249.00 218444.80 218786.14
T 0 0.00 0.00 0.00
230 2062.75 121218.72 450.00
Other 0 396.00 19679.88 27.75
-------------------------------------------------
Total 6133 18439.50 825150.54 433301.05
Center 05
Flag Claims Units Chgs Paid
-------------------------------------------------
R 1 161.25 9218.78 0.00
U 0 0.00 0.00 0.00
B 2378 5991.25 234363.95 0.00
P 3 5368.00 210953.84 213495.21
D 0 120.50 8346.80 569.70
S 0 1385.25 51254.25 0.00
H 0 4249.00 218444.80 218786.14
T 1 2.25 83.25 0.00
1514 3319.00 192798.28 450.00
Other 0 396.00 19679.88 27.75
-------------------------------------------------
Total 3897 20992.50 945143.83 433328.80
Center 06
Flag Claims Units Chgs Paid
-------------------------------------------------
R 0 161.25 9218.78 0.00
U 0 0.00 0.00 0.00
B 1633 7187.25 278615.95 619.75
P 1540 6558.25 263429.09 265932.96
D 0 120.50 8346.80 569.70
S 0 1385.25 51254.25 0.00
H 0 4249.00 218444.80 218786.14
T 0 2.25 83.25 0.00
3836 6364.25 364160.65 450.00
Other 0 396.00 19679.88 27.75
-------------------------------------------------
Total 7009 26424.00 1213233.45 486386.30
Center 07
Flag Claims Units Chgs Paid
-------------------------------------------------
R 21 171.75 9740.28 0.00
U 0 0.00 0.00 0.00
B 1178 7916.75 306390.45 619.75
P 3496 9039.00 368466.87 370970.74
D 0 120.50 8346.80 569.70
S 64 1420.25 52549.25 0.00
H 0 4249.00 218444.80 218786.14
T 0 2.25 83.25 0.00
1045 9227.50 521537.59 450.00
Other 0 396.00 19679.88 27.75
-------------------------------------------------
Total 5804 32543.00 1505239.17 591424.08
Center 09
Flag Claims Units Chgs Paid
-------------------------------------------------
R 6 179.50 10027.03 0.00
U 0 0.00 0.00 0.00
B 899 8750.00 345988.27 824.01
P 3205 11875.50 498785.14 501060.26
D 0 120.50 8346.80 569.70
S 0 1420.25 52549.25 0.00
H 0 4249.00 218444.80 218786.14
T 0 2.25 83.25 0.00
1187 12396.75 718072.46 601.51
Other 0 396.00 19679.88 27.75
-------------------------------------------------
Total 5297 39389.75 1871976.88 721869.37
Center 10
Flag Claims Units Chgs Paid
-------------------------------------------------
R 19 188.75 10369.28 0.00
U 0 0.00 0.00 0.00
B 5947 12740.25 504075.02 824.01
P 1502 13249.25 572202.58 574443.76
D 0 120.50 8346.80 569.70
S 608 1858.50 68764.50 0.00
H 0 4249.00 218444.80 218786.14
T 0 2.25 83.25 0.00
1312 15084.50 880987.64 601.51
Other 0 396.00 19679.88 27.75
-------------------------------------------------
Total 9388 47889.00 2282953.75 795252.87
Center 51
Flag Claims Units Chgs Paid
-------------------------------------------------
R 4 190.50 10434.03 0.00
U 0 0.00 0.00 0.00
B 3208 15030.25 590533.12 824.01
P 0 13249.25 572202.58 574443.76
D 0 120.50 8346.80 569.70
S 0 1858.50 68764.50 0.00
H 0 4249.00 218444.80 218786.14
T 0 2.25 83.25 0.00
1200 18099.00 1064750.46 601.51
Other 1 397.50 19792.38 27.75
-------------------------------------------------
Total 4413 53196.75 2553351.92 795252.87
Center 52
Flag Claims Units Chgs Paid
-------------------------------------------------
R 0 190.50 10434.03 0.00
U 0 0.00 0.00 0.00
B 2502 16805.50 669309.91 824.01
P 0 13249.25 572202.58 574443.76
D 0 120.50 8346.80 569.70
S 19 1879.00 69830.75 0.00
H 0 4249.00 218444.80 218786.14
T 0 2.25 83.25 0.00
620 19492.75 1154064.95 601.51
Other 0 397.50 19792.38 27.75
-------------------------------------------------
Total 3141 56386.25 2722509.45 795252.87
Center 53
Flag Claims Units Chgs Paid
-------------------------------------------------
R 3 191.25 10461.78 0.00
U 0 0.00 0.00 0.00
B 10 16814.75 669727.66 824.01
P 2187 15411.25 675657.83 677899.01
D 46 167.25 10157.30 569.70
S 0 1879.00 69830.75 0.00
H 0 4249.00 218444.80 218786.14
T 0 2.25 83.25 0.00
1765 21182.25 1242180.99 601.51
Other 0 397.50 19792.38 27.75
-------------------------------------------------
Total 4011 60294.50 2916336.74 898708.12
Center 54
Flag Claims Units Chgs Paid
-------------------------------------------------
R 6 194.50 10582.03 0.00
U 0 0.00 0.00 0.00
B 100 16911.50 675087.67 824.01
P 3964 18166.75 785716.58 787948.51
D 0 167.25 10157.30 569.70
S 0 1879.00 69830.75 0.00
H 0 4249.00 218444.80 218786.14
T 1 2.50 92.50 0.00
788 23283.00 1365907.55 601.51
Other 1 399.00 19875.63 27.75
-------------------------------------------------
Total 4860 65252.50 3155694.81 1008757.62
Center 55
Flag Claims Units Chgs Paid
-------------------------------------------------
R 5 199.25 10757.78 0.00
U 0 0.00 0.00 0.00
B 0 16911.50 675087.67 824.01
P 1075 19237.00 827856.08 830088.01
D 1 168.25 10194.30 569.70
S 2 1881.25 69914.00 0.00
H 0 4249.00 218444.80 218786.14
T 0 2.50 92.50 0.00
2508 25185.34 1487161.06 601.51
Other 0 399.00 19875.63 27.75
-------------------------------------------------
Total 3591 68233.09 3319383.82 1050897.12
Center 57
Flag Claims Units Chgs Paid
-------------------------------------------------
R 118 348.75 16458.78 0.00
U 0 0.00 0.00 0.00
B 466 17449.50 697448.92 824.01
P 1850 21209.25 906465.08 908697.01
D 0 168.25 10194.30 569.70
S 0 1881.25 69914.00 0.00
H 0 4249.00 218444.80 218786.14
T 11 36.50 1828.26 1735.76
1130 28689.34 1668710.38 164929.42
Other 0 399.00 19875.63 27.75
-------------------------------------------------
Total 3575 74430.84 3609340.15 1295569.79