CMS/EIP Fiscal Report Statewide
Services beginning 10/01/2009 ending 12/31/2009 Date of Report:02/16/2010 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 10053 31626.5 1168709.25 36.95
Subtotal (Total Children Is Unduplicated) 10053 31626.5 1168709.25 36.95
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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 1 1.00 16.30 16.30
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 67 68.00 600.44 8.83
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 56 58.00 626.40 10.80
AUDE-92568-ACOUSTIC REFLEX TESTING (MEMR) 3 3.00 25.32 8.44
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 63 64.00 1394.56 21.79
AUDE-92585-AUD EVOKED RESPONSE (DIAG) 1 1.00 54.38 54.38
AUDE-92586-AUD EVOKED RESPONSE (SCREEN) 2 2.00 60.86 30.43
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 7 7.00 197.96 28.28
AUDE-92588-OTOACOUSTIC EMISSIONS (COMP) 11 11.00 349.91 31.81
AUDE-V5090-DISPENSING FEE PER HEARING AID 1 1.00 119.60 119.60
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 63 95.00 7125.00 75.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 17 24.00 1800.00 75.00
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 31 42.50 3187.50 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 49 84.50 6337.50 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 77 112.00 6216.00 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 643 944.50 70837.50 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 261 419.50 31462.50 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 242 329.50 24712.50 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 725 1140.50 63297.75 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 448 715.00 53476.00 74.79
MED-99202-OUTPATIENT VISIT, NEW, 20 MINS 1 1.00 27.22 27.22
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 92 92.00 16297.50 177.15
MED-99204-OUTPATIENT VISIT, NEW, 45 MINS 15 15.00 1076.78 71.79
MED-99205-OUTPATIENT VISIT, NEW, 60 MINS 2 2.00 145.56 72.78
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 23 23.00 2415.00 105.00
MED-99214-OUTPATIENT VISIT, EST, 25 MINS 1 1.00 160.00 160.00
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 25 25.00 1212.50 48.50
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 69 70.00 3395.00 48.50
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 17 17.00 824.50 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 55 56.00 2716.00 48.50
SCREEN-T1023-INTERDISCIPLINARY SCREENING 45 45.00 2250.00 50.00
SPCH-92506-SPEECH EVAL BY LICENSED SLP 147 155.00 7517.50 48.50
Subtotal (Total Children Is Unduplicated) 1784 4628.00 309967.40 66.98
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 4 14.00 2582.70 184.48
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 28 54.00 1355.00 25.09
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 2776 18523.5 926082.50 50.00
HERN-T1027SC-EI HEARING SERVICES AFTER SHINE 11 39.50 1975.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 617 3172.50 215342.52 67.88
OCCT-97530HM-OT SESSION BY OT ASST 25 100.25 5445.58 54.32
PHY-97110-PT SESSION BY LICENSED PT 818 3737.89 253456.51 67.81
PHY-97110HM-PT SESSION BY PT ASST 51 186.75 10144.26 54.32
SENS-V5264-EARMOLD 1 2.00 37.44 18.72
SHIN-T1027SC-INITIAL SHINE SERVICES, INDIVIDUAL 16 37.00 1850.00 50.00
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 1253 6026.95 408871.45 67.84
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 4 9.00 488.88 54.32
SPL-92508-GROUP SPL SESSION PER CHILD 21 44.25 584.10 13.20
VISN-T1027SC-EI VISION SERVICES, INDIVIDUAL 1 21.00 1050.00 50.00
Subtotal (Total Children Is Unduplicated) 4312 31968.6 1829265.94 57.22
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Total 68223.09 3307942.59 48.49
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Number of Children (Unduplicated) With at Least One Service 10724
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Center 01
Flag Claims Units Chgs Paid
-------------------------------------------------
R 248 163.50 6236.75 0.00
U 0 0.00 0.00 0.00
B 3184 2272.25 85691.75 0.00
P 152 191.75 9584.25 9584.25
D 135 182.50 12085.50 0.00
S 2017 1494.00 55139.25 0.00
H 0 0.00 0.00 0.00
T 1 3.00 150.00 200.00
998 1920.75 100003.56 3450.00
Other 592 914.50 54548.57 0.00
-------------------------------------------------
Total 7327 7142.25 323439.63 13234.25
Center 02
Flag Claims Units Chgs Paid
-------------------------------------------------
R 17 177.00 6736.25 0.00
U 0 0.00 0.00 0.00
B 649 2808.75 105329.00 0.00
P 1 192.25 9602.75 9584.25
D 0 182.50 12085.50 0.00
S 1 1495.25 55185.50 0.00
H 0 0.00 0.00 0.00
T 0 3.00 150.00 200.00
95 2067.00 108375.06 3450.00
Other 0 914.50 54548.57 0.00
-------------------------------------------------
Total 763 7840.25 352012.63 13234.25
Center 03
Flag Claims Units Chgs Paid
-------------------------------------------------
R 47 218.00 8458.75 0.00
U 0 0.00 0.00 0.00
B 62 2855.50 107153.25 0.00
P 2227 1773.00 72508.00 72461.75
D 0 182.50 12085.50 0.00
S 0 1495.25 55185.50 0.00
H 0 0.00 0.00 0.00
T 0 3.00 150.00 200.00
107 2157.50 111760.56 3450.00
Other 70 984.50 55651.24 0.00
-------------------------------------------------
Total 2513 9669.25 422952.80 76111.75
Center 04
Flag Claims Units Chgs Paid
-------------------------------------------------
R 283 521.25 20433.00 0.00
U 0 0.00 0.00 0.00
B 1736 4623.50 179620.00 0.00
P 1976 3794.25 147520.25 147295.18
D 0 182.50 12085.50 0.00
S 0 1495.25 55185.50 0.00
H 1287 4042.50 208806.74 208848.22
T 1 4.25 196.25 200.00
362 2789.25 161925.91 3853.64
Other 0 984.50 55651.24 0.00
-------------------------------------------------
Total 5645 18437.25 841424.39 360197.04
Center 05
Flag Claims Units Chgs Paid
-------------------------------------------------
R 133 603.25 23467.00 0.00
U 0 0.00 0.00 0.00
B 1813 5568.00 214737.50 0.00
P 0 3794.25 147520.25 147295.18
D 0 182.50 12085.50 0.00
S 0 1495.25 55185.50 0.00
H 0 4042.50 208806.74 208848.22
T 0 4.25 196.25 200.00
703 3385.00 194684.30 3853.64
Other 0 984.50 55651.24 0.00
-------------------------------------------------
Total 2649 20059.50 912334.28 360197.04
Center 06
Flag Claims Units Chgs Paid
-------------------------------------------------
R 25 618.00 24012.75 0.00
U 0 0.00 0.00 0.00
B 165 5673.00 218622.50 434.75
P 3484 6037.00 230939.00 230713.93
D 0 182.50 12085.50 0.00
S 0 1495.25 55185.50 0.00
H 0 4042.50 208806.74 208848.22
T 0 4.25 196.25 200.00
3059 6007.00 350129.67 3853.64
Other 0 984.50 55651.24 0.00
-------------------------------------------------
Total 6733 25044.00 1155629.15 444050.54
Center 07
Flag Claims Units Chgs Paid
-------------------------------------------------
R 232 766.00 29488.75 0.00
U 0 0.00 0.00 0.00
B 4023 8291.75 324462.81 434.75
P 346 6237.00 238313.25 238088.18
D 0 182.50 12085.50 0.00
S 5 1500.50 55379.75 0.00
H 0 4042.50 208806.74 208848.22
T 0 4.25 196.25 200.00
1139 9017.75 514709.85 3853.64
Other 0 984.50 55651.24 0.00
-------------------------------------------------
Total 5745 31026.75 1439094.14 451424.79
Center 09
Flag Claims Units Chgs Paid
-------------------------------------------------
R 107 836.50 32179.75 0.00
U 0 0.00 0.00 0.00
B 2955 10761.75 437916.47 481.00
P 686 6862.50 267565.93 350372.36
D 0 182.50 12085.50 0.00
S 0 1500.50 55379.75 0.00
H 0 4042.50 208806.74 208848.22
T 0 4.25 196.25 200.00
1487 12848.75 749076.94 3853.64
Other 0 984.50 55651.24 0.00
-------------------------------------------------
Total 5235 38023.75 1818858.57 563755.22
Center 10
Flag Claims Units Chgs Paid
-------------------------------------------------
R 607 1195.50 45575.75 0.00
U 0 0.00 0.00 0.00
B 5946 14543.00 587531.47 481.00
P 502 7355.00 295534.68 378285.61
D 0 182.50 12085.50 0.00
S 118 1564.50 57747.75 0.00
H 0 4042.50 208806.74 208848.22
T 0 4.25 196.25 200.00
1273 15581.50 913309.90 3853.64
Other 0 984.50 55651.24 0.00
-------------------------------------------------
Total 8446 45453.25 2176439.28 591668.47
Center 51
Flag Claims Units Chgs Paid
-------------------------------------------------
R 57 1237.25 47310.50 0.00
U 0 0.00 0.00 0.00
B 3148 16963.75 678221.53 481.00
P 0 7355.00 295534.68 378285.61
D 0 182.50 12085.50 0.00
S 0 1564.50 57747.75 0.00
H 0 4042.50 208806.74 208848.22
T 1 5.25 233.25 200.00
1065 18106.75 1065043.36 3853.64
Other 0 984.50 55651.24 0.00
-------------------------------------------------
Total 4271 50442.00 2420634.55 591668.47
Center 52
Flag Claims Units Chgs Paid
-------------------------------------------------
R 234 1415.25 56337.26 0.00
U 0 0.00 0.00 0.00
B 880 17528.75 704571.00 481.00
P 1202 8039.00 321236.68 403987.61
D 0 182.50 12085.50 0.00
S 67 1616.75 59607.00 0.00
H 0 4042.50 208806.74 208848.22
T 0 5.25 233.25 200.00
627 19555.09 1158146.84 3853.64
Other 0 984.50 55651.24 0.00
-------------------------------------------------
Total 3010 53369.59 2576675.51 617370.47
Center 53
Flag Claims Units Chgs Paid
-------------------------------------------------
R 334 1761.25 72402.64 0.00
U 0 0.00 0.00 0.00
B 595 17965.00 721423.25 481.00
P 1302 9224.00 375398.68 458149.61
D 4 187.50 12385.50 0.00
S 0 1616.75 59607.00 0.00
H 0 4042.50 208806.74 208848.22
T 0 5.25 233.25 200.00
1929 21337.34 1253586.37 4053.64
Other 0 984.50 55651.24 0.00
-------------------------------------------------
Total 4164 57124.09 2759494.67 671732.47
Center 54
Flag Claims Units Chgs Paid
-------------------------------------------------
R 68 1826.25 75257.14 0.00
U 0 0.00 0.00 0.00
B 1842 19408.75 782058.43 481.00
P 2080 10719.50 437224.04 519937.09
D 40 216.00 13848.98 0.00
S 0 1616.75 59607.00 0.00
H 0 4042.50 208806.74 208848.22
T 0 5.25 233.25 200.00
469 22489.09 1321990.55 4053.64
Other 0 984.50 55651.24 0.00
-------------------------------------------------
Total 4499 61308.59 2954677.37 733519.95
Center 55
Flag Claims Units Chgs Paid
-------------------------------------------------
R 20 1848.50 76081.89 0.00
U 0 0.00 0.00 0.00
B 247 19616.00 789495.43 481.00
P 808 11450.75 465840.79 548544.59
D 0 216.00 13848.98 0.00
S 2 1619.25 59699.50 0.00
H 0 4042.50 208806.74 208848.22
T 0 5.25 233.25 200.00
1951 24015.34 1418955.25 4053.64
Other 0 984.50 55651.24 0.00
-------------------------------------------------
Total 3028 63798.09 3088613.07 762127.45
Center 57
Flag Claims Units Chgs Paid
-------------------------------------------------
R 182 2028.75 82835.89 0.00
U 0 0.00 0.00 0.00
B 941 20566.00 828501.93 481.00
P 1 11452.75 465914.79 548618.59
D 0 216.00 13848.98 0.00
S 0 1619.25 59699.50 0.00
H 0 4042.50 208806.74 208848.22
T 4 24.25 1183.25 1150.00
1082 27289.09 1591500.27 150531.27
Other 0 984.50 55651.24 0.00
-------------------------------------------------
Total 2210 68223.09 3307942.59 909629.08