CMS/EIP Fiscal Report Statewide
Services beginning 07/01/2009 ending 09/30/2009 Date of Report:11/17/2009 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 9752 31902.8 1178873.75 36.95
Subtotal (Total Children Is Unduplicated) 9752 31902.8 1178873.75 36.95
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Screening, Eval, and Assessment,Class #02
AUD-92626-EVAL OF AUD REHAB STATUS 2 2.00 72.14 36.07
AUDE-92552-PURE TONE AUDIOMETRY -AIR ONLY 4 4.00 42.48 10.62
AUDE-92553-PURE TONE AUDIOMETRY AIR & BONE 1 1.00 16.30 16.30
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 83 83.00 732.89 8.83
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 76 77.00 831.18 10.79
AUDE-92568-ACOUSTIC REFLEX TESTING (MEMR) 1 1.00 8.44 8.44
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 82 82.00 1786.78 21.79
AUDE-92585-AUD EVOKED RESPONSE (DIAG) 4 4.00 217.52 54.38
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 7 7.00 197.96 28.28
AUDE-92588-OTOACOUSTIC EMISSIONS (COMP) 15 15.00 477.15 31.81
AUDE-V5010-ASSESSMENT FOR HEARING AID 1 1.00 46.80 46.80
AUDE-V5090-DISPENSING FEE PER HEARING AID 1 2.00 239.20 119.60
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 83 124.00 9300.00 75.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 22 28.50 2137.50 75.00
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 25 34.00 2550.00 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 55 82.50 6187.50 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 110 154.00 8547.00 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 730 1037.29 77375.27 74.59
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 258 409.00 30622.00 74.87
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 210 287.29 21403.27 74.50
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 776 1195.50 66322.50 55.48
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 498 817.50 61200.00 74.86
MED-99202-OUTPATIENT VISIT, NEW, 20 MINS 1 1.00 27.22 27.22
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 88 88.00 15413.00 175.15
MED-99204-OUTPATIENT VISIT, NEW, 45 MINS 16 16.00 1351.78 84.49
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 31 31.00 3255.00 105.00
MED-99214-OUTPATIENT VISIT, EST, 25 MINS 1 1.00 160.00 160.00
MED-99215-OUTPATIENT VISIT, EST, 40 MINS 1 1.00 50.15 50.15
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 36 42.00 2037.00 48.50
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 82 85.00 4122.50 48.50
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 49 49.00 2376.50 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 64 64.00 3104.00 48.50
SCREEN-T1023-INTERDISCIPLINARY SCREENING 45 45.00 2250.00 50.00
SPCH-92506-SPEECH EVAL BY LICENSED SLP 163 163.00 7905.50 48.50
Subtotal (Total Children Is Unduplicated) 1986 5034.58 332366.53 66.02
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 4 16.00 4868.73 304.30
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 25 75.00 1875.00 25.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 2783 19064.5 952806.00 49.98
HERN-T1027SC-EI HEARING SERVICES AFTER SHINE 10 30.00 1500.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 680 3396.00 230469.63 67.87
OCCT-97530HM-OT SESSION BY OT ASST 37 154.25 8378.86 54.32
PHY-97110-PT SESSION BY LICENSED PT 848 3758.00 255039.26 67.87
PHY-97110HM-PT SESSION BY PT ASST 53 256.00 13905.92 54.32
SENS-V5264-EARMOLD 2 6.00 112.32 18.72
SHIN-T1027SC-INITIAL SHINE SERVICES, INDIVIDUAL 9 19.75 987.50 50.00
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 1262 5951.75 403260.19 67.75
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 10 31.00 1683.92 54.32
SPL-92508-GROUP SPL SESSION PER CHILD 10 20.25 268.50 13.26
VISN-T1027SC-EI VISION SERVICES, INDIVIDUAL 3 23.00 1150.00 50.00
Subtotal (Total Children Is Unduplicated) 4327 32801.5 1876305.83 57.20
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Total 69738.83 3387546.11 48.57
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Number of Children (Unduplicated) With at Least One Service 10521
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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 3054 2093.75 80194.50 0.00
P 500 313.00 11684.75 11694.00
D 64 49.25 2608.25 0.00
S 1004 814.00 30073.00 0.00
H 15 18.50 1358.25 0.00
T 0 0.00 0.00 0.00
858 1649.25 90653.55 292.88
Other 199 388.50 21948.20 0.00
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Total 5694 5326.25 238520.50 11986.88
Center 02
Flag Claims Units Chgs Paid
-------------------------------------------------
R 83 55.75 2025.75 0.00
U 0 0.00 0.00 0.00
B 761 2734.50 103661.75 0.00
P 0 313.00 11684.75 11694.00
D 0 49.25 2608.25 0.00
S 0 814.00 30073.00 0.00
H 0 18.50 1358.25 0.00
T 0 0.00 0.00 0.00
101 1839.25 102189.05 292.88
Other 0 388.50 21948.20 0.00
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Total 945 6212.75 275549.00 11986.88
Center 03
Flag Claims Units Chgs Paid
-------------------------------------------------
R 8 58.00 2109.00 0.00
U 0 0.00 0.00 0.00
B 54 2786.25 105996.50 37.00
P 2068 1712.75 67001.75 66909.25
D 0 49.25 2608.25 0.00
S 0 814.00 30073.00 0.00
H 0 18.50 1358.25 0.00
T 0 0.00 0.00 0.00
304 2037.25 109550.80 292.88
Other 55 443.00 22904.57 0.00
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Total 2489 7919.00 341602.12 67239.13
Center 04
Flag Claims Units Chgs Paid
-------------------------------------------------
R 0 58.00 2109.00 0.00
U 0 0.00 0.00 0.00
B 1583 4371.25 171950.00 37.00
P 2795 4456.25 171093.25 168725.98
D 4 57.00 2947.00 338.75
S 0 814.00 30073.00 0.00
H 1205 4001.00 204239.75 203441.45
T 0 0.00 0.00 0.00
284 2518.75 149061.50 292.88
Other 0 443.00 22904.57 0.00
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Total 5871 16719.25 754378.07 372836.06
Center 05
Flag Claims Units Chgs Paid
-------------------------------------------------
R 0 58.00 2109.00 0.00
U 0 0.00 0.00 0.00
B 2326 5628.75 218477.50 37.00
P 6 4461.75 171296.75 168929.48
D 0 57.00 2947.00 338.75
S 0 814.00 30073.00 0.00
H 0 4001.00 204239.75 203441.45
T 0 0.00 0.00 0.00
1294 3479.75 204167.94 292.88
Other 0 443.00 22904.57 0.00
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Total 3626 18943.25 856215.51 373039.56
Center 06
Flag Claims Units Chgs Paid
-------------------------------------------------
R 1 59.00 2146.00 0.00
U 0 0.00 0.00 0.00
B 3985 8261.00 315870.75 37.00
P 0 4461.75 171296.75 168929.48
D 0 57.00 2947.00 338.75
S 0 814.00 30073.00 0.00
H 0 4001.00 204239.75 203441.45
T 0 0.00 0.00 0.00
3021 6077.00 356338.95 292.88
Other 0 443.00 22904.57 0.00
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Total 7007 24173.75 1105816.77 373039.56
Center 07
Flag Claims Units Chgs Paid
-------------------------------------------------
R 13 64.50 2349.50 0.00
U 0 0.00 0.00 0.00
B 2813 10072.75 386750.50 37.00
P 1971 5801.25 228784.25 226493.48
D 0 57.00 2947.00 338.75
S 4 816.00 30147.00 0.00
H 0 4001.00 204239.75 203441.45
T 0 0.00 0.00 0.00
1156 9331.25 533319.36 292.88
Other 0 443.00 22904.57 0.00
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Total 5957 30586.75 1411441.93 430603.56
Center 09
Flag Claims Units Chgs Paid
-------------------------------------------------
R 13 76.50 2793.50 27.75
U 0 0.00 0.00 0.00
B 938 10947.25 430981.39 372.00
P 2490 7948.25 327044.40 324693.88
D 0 57.00 2947.00 338.75
S 0 816.00 30147.00 0.00
H 1 4001.50 204258.25 203459.95
T 0 0.00 0.00 0.00
1220 12679.75 738734.58 292.88
Other 0 443.00 22904.57 0.00
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Total 4662 36969.25 1759810.69 529185.21
Center 10
Flag Claims Units Chgs Paid
-------------------------------------------------
R 33 109.25 4118.25 27.75
U 0 0.00 0.00 0.00
B 2690 12628.00 493886.39 372.00
P 3715 10561.00 440424.65 437904.13
D 0 57.00 2947.00 338.75
S 402 1044.00 38583.00 0.00
H 0 4001.50 204258.25 203459.95
T 0 0.00 0.00 0.00
1541 15747.25 924404.58 292.88
Other 0 443.00 22904.57 0.00
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Total 8381 44591.00 2131526.69 642395.46
Center 51
Flag Claims Units Chgs Paid
-------------------------------------------------
R 8 112.25 4229.25 27.75
U 0 0.00 0.00 0.00
B 3345 15024.50 584199.80 372.00
P 0 10561.00 440424.65 437904.13
D 0 57.00 2947.00 338.75
S 0 1044.00 38583.00 0.00
H 0 4001.50 204258.25 203459.95
T 0 0.00 0.00 0.00
1021 18318.00 1076897.26 292.88
Other 0 443.00 22904.57 0.00
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Total 4374 49561.25 2374443.78 642395.46
Center 52
Flag Claims Units Chgs Paid
-------------------------------------------------
R 14 124.00 5033.88 27.75
U 0 0.00 0.00 0.00
B 2360 16527.75 650381.76 372.00
P 0 10561.00 440424.65 437904.13
D 0 57.00 2947.00 338.75
S 37 1080.50 40235.75 0.00
H 0 4001.50 204258.25 203459.95
T 0 0.00 0.00 0.00
681 19788.00 1168781.37 292.88
Other 0 443.00 22904.57 0.00
-------------------------------------------------
Total 3092 52582.75 2534967.23 642395.46
Center 53
Flag Claims Units Chgs Paid
-------------------------------------------------
R 18 143.75 6050.38 27.75
U 0 0.00 0.00 0.00
B 537 16996.00 669226.01 372.00
P 1070 11676.58 495879.94 493303.92
D 4 63.00 3306.50 338.75
S 0 1080.50 40235.75 0.00
H 0 4001.50 204258.25 203459.95
T 0 0.00 0.00 0.00
2036 21700.75 1270347.58 1092.88
Other 0 443.00 22904.57 0.00
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Total 3665 56105.08 2712208.98 698595.25
Center 54
Flag Claims Units Chgs Paid
-------------------------------------------------
R 32 178.00 7873.88 27.75
U 0 0.00 0.00 0.00
B 81 17064.25 672140.26 372.00
P 3764 14357.83 603741.44 601115.42
D 0 63.00 3306.50 338.75
S 0 1080.50 40235.75 0.00
H 0 4001.50 204258.25 203459.95
T 1 0.25 9.25 0.00
881 23918.00 1399605.96 1092.88
Other 1 443.25 22913.82 0.00
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Total 4760 61106.58 2954085.11 806406.75
Center 55
Flag Claims Units Chgs Paid
-------------------------------------------------
R 0 178.00 7873.88 27.75
U 0 0.00 0.00 0.00
B 9 17070.75 672380.76 372.00
P 1348 15587.08 652180.19 649454.17
D 0 63.00 3306.50 338.75
S 1 1081.50 40272.75 0.00
H 0 4001.50 204258.25 203459.95
T 0 0.25 9.25 0.00
2144 25599.75 1507570.45 1092.88
Other 11 452.50 23256.07 0.00
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Total 3513 64034.33 3111108.10 854745.50
Center 57
Flag Claims Units Chgs Paid
-------------------------------------------------
R 26 207.25 9455.88 27.75
U 0 0.00 0.00 0.00
B 520 17624.75 693290.76 372.00
P 1179 16818.58 702169.19 699443.17
D 0 63.00 3306.50 338.75
S 0 1081.50 40272.75 0.00
H 1 4002.00 204276.75 203478.45
T 3 13.25 659.25 650.00
1318 29476.00 1710858.96 176745.43
Other 0 452.50 23256.07 0.00
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Total 3047 69738.83 3387546.11 1081055.55