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: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 11080 36327.8 1342441.50 36.95
Subtotal (Total Children Is Unduplicated) 11080 36327.8 1342441.50 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) 87 87.00 768.21 8.83
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 79 80.00 863.58 10.79
AUDE-92568-ACOUSTIC REFLEX TESTING (MEMR) 1 1.00 8.44 8.44
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 86 86.00 1873.94 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 94 138.50 10387.50 75.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 29 39.00 2925.00 75.00
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 35 47.00 3525.00 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 67 94.00 7050.00 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 131 188.00 10434.00 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 1005 1373.29 102469.27 74.62
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 365 559.50 41909.50 74.91
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 335 442.79 33039.27 74.62
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 1097 1650.00 91547.25 55.48
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 679 1052.50 78825.00 74.89
MED-99202-OUTPATIENT VISIT, NEW, 20 MINS 1 1.00 27.22 27.22
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 109 110.00 18760.50 170.55
MED-99204-OUTPATIENT VISIT, NEW, 45 MINS 17 17.00 1409.05 82.89
MED-99205-OUTPATIENT VISIT, NEW, 60 MINS 6 6.00 436.68 72.78
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 11 11.00 551.65 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 66 66.00 3201.00 48.50
SCREEN-T1023-INTERDISCIPLINARY SCREENING 88 91.00 4550.00 50.00
SPCH-92506-SPEECH EVAL BY LICENSED SLP 165 165.00 8002.50 48.50
Subtotal (Total Children Is Unduplicated) 2610 6549.58 435825.11 66.54
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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 26 76.00 1900.00 25.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 2804 19182.5 958706.00 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 855 3771.25 255938.67 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 1269 5971.75 404617.79 67.76
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) 4359 32953.8 1884487.84 57.19
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Total 75831.08 3662754.45 48.30
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Number of Children (Unduplicated) With at Least One Service 11885
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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 3724 2616.75 101519.75 0.00
P 603 395.00 14728.00 14737.25
D 87 68.75 3737.00 0.00
S 1172 964.00 35623.00 0.00
H 28 31.00 2295.75 0.00
T 0 0.00 0.00 0.00
926 1747.50 95062.10 292.88
Other 224 416.50 23943.95 0.00
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Total 6764 6239.50 276909.55 15030.13
Center 02
Flag Claims Units Chgs Paid
-------------------------------------------------
R 85 58.00 2109.00 0.00
U 0 0.00 0.00 0.00
B 844 3339.75 128002.50 0.00
P 0 395.00 14728.00 14737.25
D 0 68.75 3737.00 0.00
S 0 964.00 35623.00 0.00
H 0 31.00 2295.75 0.00
T 0 0.00 0.00 0.00
122 1980.25 109143.85 292.88
Other 0 416.50 23943.95 0.00
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Total 1051 7253.25 319583.05 15030.13
Center 03
Flag Claims Units Chgs Paid
-------------------------------------------------
R 8 60.25 2192.25 0.00
U 0 0.00 0.00 0.00
B 70 3412.25 131463.50 37.00
P 2327 2037.00 80006.50 79830.75
D 0 68.75 3737.00 0.00
S 0 964.00 35623.00 0.00
H 0 31.00 2295.75 0.00
T 0 0.00 0.00 0.00
320 2200.75 117338.10 292.88
Other 60 476.00 24972.36 0.00
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Total 2785 9250.00 397628.46 80160.63
Center 04
Flag Claims Units Chgs Paid
-------------------------------------------------
R 0 60.25 2192.25 0.00
U 0 0.00 0.00 0.00
B 1866 5299.00 210991.75 37.00
P 3102 5138.50 197936.00 194994.27
D 4 76.50 4075.75 338.75
S 0 964.00 35623.00 0.00
H 1212 4036.50 206343.63 204607.83
T 0 0.00 0.00 0.00
298 2696.25 159290.80 292.88
Other 0 476.00 24972.36 0.00
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Total 6482 18747.00 841425.54 400270.73
Center 05
Flag Claims Units Chgs Paid
-------------------------------------------------
R 0 60.25 2192.25 0.00
U 0 0.00 0.00 0.00
B 2649 6750.00 264704.90 37.00
P 14 5150.25 198409.75 195468.02
D 0 76.50 4075.75 338.75
S 0 964.00 35623.00 0.00
H 0 4036.50 206343.63 204607.83
T 0 0.00 0.00 0.00
1339 3705.25 217040.27 292.88
Other 0 476.00 24972.36 0.00
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Total 4002 21218.75 953361.91 400744.48
Center 06
Flag Claims Units Chgs Paid
-------------------------------------------------
R 1 61.25 2229.25 0.00
U 0 0.00 0.00 0.00
B 4490 9732.50 375057.40 37.00
P 0 5150.25 198409.75 195468.02
D 0 76.50 4075.75 338.75
S 0 964.00 35623.00 0.00
H 0 4036.50 206343.63 204607.83
T 0 0.00 0.00 0.00
3121 6404.00 375666.21 292.88
Other 0 476.00 24972.36 0.00
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Total 7612 26901.00 1222377.35 400744.48
Center 07
Flag Claims Units Chgs Paid
-------------------------------------------------
R 13 66.75 2432.75 0.00
U 0 0.00 0.00 0.00
B 2924 11644.50 450127.40 37.00
P 2071 6581.50 260018.75 257153.52
D 0 76.50 4075.75 338.75
S 4 966.00 35697.00 0.00
H 0 4036.50 206343.63 204607.83
T 0 0.00 0.00 0.00
1171 9685.25 554388.87 292.88
Other 0 476.00 24972.36 0.00
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Total 6183 33533.00 1538056.51 462429.98
Center 09
Flag Claims Units Chgs Paid
-------------------------------------------------
R 15 82.75 3061.75 27.75
U 0 0.00 0.00 0.00
B 1024 12628.00 500305.04 372.00
P 2782 9032.00 374554.15 371629.16
D 0 76.50 4075.75 338.75
S 0 966.00 35697.00 0.00
H 1 4037.00 206362.13 204626.33
T 0 0.00 0.00 0.00
1227 13042.50 760315.34 292.88
Other 0 476.00 24972.36 0.00
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Total 5049 40340.75 1909343.52 577286.87
Center 10
Flag Claims Units Chgs Paid
-------------------------------------------------
R 46 130.25 4998.00 27.75
U 0 0.00 0.00 0.00
B 3084 14663.75 576867.54 372.00
P 4439 12437.25 529595.90 526500.91
D 0 76.50 4075.75 338.75
S 468 1244.50 46001.50 0.00
H 0 4037.00 206362.13 204626.33
T 0 0.00 0.00 0.00
1546 16118.00 946387.78 292.88
Other 0 476.00 24972.36 0.00
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Total 9583 49183.25 2339260.96 732158.62
Center 51
Flag Claims Units Chgs Paid
-------------------------------------------------
R 10 135.25 5259.00 27.75
U 0 0.00 0.00 0.00
B 3731 17396.00 680058.20 372.00
P 0 12437.25 529595.90 526500.91
D 0 76.50 4075.75 338.75
S 0 1244.50 46001.50 0.00
H 0 4037.00 206362.13 204626.33
T 0 0.00 0.00 0.00
1052 18726.75 1101577.62 292.88
Other 0 476.00 24972.36 0.00
-------------------------------------------------
Total 4793 54529.25 2597902.46 732158.62
Center 52
Flag Claims Units Chgs Paid
-------------------------------------------------
R 17 151.50 6401.13 27.75
U 0 0.00 0.00 0.00
B 2552 19067.00 754002.16 372.00
P 0 12437.25 529595.90 526500.91
D 0 76.50 4075.75 338.75
S 41 1285.25 47811.50 0.00
H 0 4037.00 206362.13 204626.33
T 0 0.00 0.00 0.00
688 20203.75 1193804.23 292.88
Other 0 476.00 24972.36 0.00
-------------------------------------------------
Total 3298 57734.25 2767025.16 732158.62
Center 53
Flag Claims Units Chgs Paid
-------------------------------------------------
R 18 171.25 7417.63 27.75
U 0 0.00 0.00 0.00
B 582 19582.00 774615.16 372.00
P 1141 13647.33 590042.19 586891.70
D 4 82.50 4435.25 338.75
S 0 1285.25 47811.50 0.00
H 0 4037.00 206362.13 204626.33
T 0 0.00 0.00 0.00
2040 22124.50 1295970.44 1092.88
Other 0 476.00 24972.36 0.00
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Total 3785 61405.83 2951626.66 793349.41
Center 54
Flag Claims Units Chgs Paid
-------------------------------------------------
R 32 205.50 9241.13 27.75
U 0 0.00 0.00 0.00
B 88 19657.50 777797.66 372.00
P 4244 16711.08 714039.94 710839.45
D 0 82.50 4435.25 338.75
S 1 1286.25 47861.50 0.00
H 0 4037.00 206362.13 204626.33
T 1 0.25 9.25 0.00
906 24367.25 1426989.98 1092.88
Other 1 476.25 24981.61 0.00
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Total 5273 66823.58 3211718.45 917297.16
Center 55
Flag Claims Units Chgs Paid
-------------------------------------------------
R 0 205.50 9241.13 27.75
U 0 0.00 0.00 0.00
B 9 19664.00 778038.16 372.00
P 1506 18111.83 769394.19 765993.70
D 0 82.50 4435.25 338.75
S 3 1290.25 48009.50 0.00
H 0 4037.00 206362.13 204626.33
T 0 0.25 9.25 0.00
2196 26131.50 1540159.97 1092.88
Other 11 485.50 25323.86 0.00
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Total 3725 70008.33 3380973.44 972451.41
Center 57
Flag Claims Units Chgs Paid
-------------------------------------------------
R 26 234.75 10823.13 27.75
U 0 0.00 0.00 0.00
B 541 20249.50 800198.41 372.00
P 1228 19412.58 822348.69 818948.20
D 0 82.50 4435.25 338.75
S 0 1290.25 48009.50 0.00
H 1 4037.50 206380.63 204644.83
T 3 13.25 659.25 650.00
1332 30025.25 1744575.73 176745.43
Other 0 485.50 25323.86 0.00
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Total 3131 75831.08 3662754.45 1201726.96