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: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 11273 35597.8 1315423.50 36.95
Subtotal (Total Children Is Unduplicated) 11273 35597.8 1315423.50 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) 68 69.00 609.27 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 64 65.00 1416.35 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 71 105.00 7875.00 75.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 22 31.00 2325.00 75.00
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 38 51.00 3825.00 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 55 93.00 6975.00 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 89 129.50 7187.25 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 864 1231.50 92326.00 74.97
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 380 596.50 44737.50 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 350 469.00 35175.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 1013 1563.50 86719.75 55.47
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 614 942.50 70538.50 74.84
MED-99202-OUTPATIENT VISIT, NEW, 20 MINS 1 1.00 27.22 27.22
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 111 111.00 19812.50 178.49
MED-99204-OUTPATIENT VISIT, NEW, 45 MINS 17 17.00 1626.78 95.69
MED-99205-OUTPATIENT VISIT, NEW, 60 MINS 4 4.00 291.12 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
MED-99215-OUTPATIENT VISIT, EST, 40 MINS 6 6.00 300.90 50.15
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 56 57.00 2764.50 48.50
SCREEN-T1023-INTERDISCIPLINARY SCREENING 68 68.00 3400.00 50.00
SPCH-92506-SPEECH EVAL BY LICENSED SLP 150 158.00 7663.00 48.50
Subtotal (Total Children Is Unduplicated) 2312 5991.50 405085.23 67.61
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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 2797 18650.8 932445.00 50.00
HERN-T1027SC-EI HEARING SERVICES AFTER SHINE 11 39.50 1975.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 621 3184.50 216157.08 67.88
OCCT-97530HM-OT SESSION BY OT ASST 25 100.25 5445.58 54.32
PHY-97110-PT SESSION BY LICENSED PT 825 3775.14 255985.04 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 17 38.00 1900.00 50.00
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 1259 6039.95 409753.89 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) 4343 32159.1 1839903.97 57.21
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Total 73748.34 3560412.70 48.28
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Number of Children (Unduplicated) With at Least One Service 11985
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Center 01
Flag Claims Units Chgs Paid
-------------------------------------------------
R 270 181.50 7041.50 0.00
U 0 0.00 0.00 0.00
B 3664 2688.50 101272.75 0.00
P 154 195.25 9726.75 9634.25
D 164 224.25 14950.00 0.00
S 2289 1697.50 62668.75 0.00
H 0 0.00 0.00 0.00
T 1 3.00 150.00 200.00
1035 1996.00 103966.57 3500.00
Other 609 946.50 56642.73 0.00
-------------------------------------------------
Total 8186 7932.50 356419.05 13334.25
Center 02
Flag Claims Units Chgs Paid
-------------------------------------------------
R 17 195.00 7541.00 0.00
U 0 0.00 0.00 0.00
B 716 3291.50 123315.00 0.00
P 1 195.75 9745.25 9634.25
D 0 224.25 14950.00 0.00
S 1 1698.75 62715.00 0.00
H 0 0.00 0.00 0.00
T 0 3.00 150.00 200.00
112 2171.25 114195.82 3500.00
Other 0 946.50 56642.73 0.00
-------------------------------------------------
Total 847 8726.00 389254.80 13334.25
Center 03
Flag Claims Units Chgs Paid
-------------------------------------------------
R 51 241.00 9448.50 0.00
U 0 0.00 0.00 0.00
B 71 3348.00 125500.00 0.00
P 2507 2032.75 82583.25 82447.50
D 0 224.25 14950.00 0.00
S 0 1698.75 62715.00 0.00
H 0 0.00 0.00 0.00
T 0 3.00 150.00 200.00
122 2277.00 118145.57 3500.00
Other 72 1018.50 57776.02 0.00
-------------------------------------------------
Total 2823 10843.25 471268.34 86147.50
Center 04
Flag Claims Units Chgs Paid
-------------------------------------------------
R 322 578.50 22916.50 0.00
U 0 0.00 0.00 0.00
B 2034 5419.75 211054.00 0.00
P 2173 4279.75 165948.25 165633.68
D 0 224.25 14950.00 0.00
S 0 1698.75 62715.00 0.00
H 1296 4075.50 210599.78 210641.26
T 1 4.25 196.25 200.00
404 2954.00 173273.17 3903.64
Other 0 1018.50 57776.02 0.00
-------------------------------------------------
Total 6230 20253.25 919428.97 380378.58
Center 05
Flag Claims Units Chgs Paid
-------------------------------------------------
R 149 674.25 26459.25 0.00
U 0 0.00 0.00 0.00
B 2040 6493.75 250976.15 0.00
P 1 4280.75 165998.25 165683.68
D 0 224.25 14950.00 0.00
S 0 1698.75 62715.00 0.00
H 0 4075.50 210599.78 210641.26
T 0 4.25 196.25 200.00
795 3606.50 208511.62 3903.64
Other 0 1018.50 57776.02 0.00
-------------------------------------------------
Total 2985 22076.50 998182.32 380428.58
Center 06
Flag Claims Units Chgs Paid
-------------------------------------------------
R 26 689.50 27023.50 0.00
U 0 0.00 0.00 0.00
B 192 6615.25 255471.65 434.75
P 3893 6782.75 259085.25 258770.68
D 0 224.25 14950.00 0.00
S 0 1698.75 62715.00 0.00
H 0 4075.50 210599.78 210641.26
T 0 4.25 196.25 200.00
3161 6326.25 370127.05 4128.64
Other 0 1018.50 57776.02 0.00
-------------------------------------------------
Total 7272 27435.00 1257944.50 474175.33
Center 07
Flag Claims Units Chgs Paid
-------------------------------------------------
R 244 846.50 32832.50 0.00
U 0 0.00 0.00 0.00
B 4277 9459.25 370812.46 434.75
P 355 6991.25 267002.00 266687.43
D 0 224.25 14950.00 0.00
S 5 1704.00 62909.25 0.00
H 0 4075.50 210599.78 210641.26
T 0 4.25 196.25 200.00
1161 9369.00 536771.73 4128.64
Other 0 1018.50 57776.02 0.00
-------------------------------------------------
Total 6042 33692.50 1553849.99 482092.08
Center 09
Flag Claims Units Chgs Paid
-------------------------------------------------
R 117 932.25 36220.75 0.00
U 0 0.00 0.00 0.00
B 3160 12179.25 498057.62 481.00
P 753 7697.75 301259.18 383976.11
D 0 224.25 14950.00 0.00
S 0 1704.00 62909.25 0.00
H 0 4075.50 210599.78 210641.26
T 0 4.25 196.25 200.00
1501 13218.75 772150.07 4128.64
Other 0 1018.50 57776.02 0.00
-------------------------------------------------
Total 5531 41054.50 1954118.92 599427.01
Center 10
Flag Claims Units Chgs Paid
-------------------------------------------------
R 684 1370.25 53438.50 0.00
U 0 0.00 0.00 0.00
B 6743 16686.75 678548.37 481.00
P 704 8475.50 346926.93 429588.36
D 0 224.25 14950.00 0.00
S 128 1773.25 65471.50 0.00
H 0 4075.50 210599.78 210641.26
T 0 4.25 196.25 200.00
1281 15967.50 937469.11 4128.64
Other 0 1018.50 57776.02 0.00
-------------------------------------------------
Total 9540 49595.75 2365376.46 645039.26
Center 51
Flag Claims Units Chgs Paid
-------------------------------------------------
R 60 1416.00 55416.25 0.00
U 0 0.00 0.00 0.00
B 3379 19314.25 777127.68 481.00
P 0 8475.50 346926.93 429588.36
D 0 224.25 14950.00 0.00
S 0 1773.25 65471.50 0.00
H 0 4075.50 210599.78 210641.26
T 1 5.25 233.25 200.00
1103 18531.00 1092040.98 4128.64
Other 0 1018.50 57776.02 0.00
-------------------------------------------------
Total 4543 54833.50 2620542.39 645039.26
Center 52
Flag Claims Units Chgs Paid
-------------------------------------------------
R 234 1594.00 64443.01 0.00
U 0 0.00 0.00 0.00
B 953 19948.00 806500.65 481.00
P 1311 9247.50 376195.68 458857.11
D 0 224.25 14950.00 0.00
S 82 1835.50 67700.75 0.00
H 0 4075.50 210599.78 210641.26
T 0 5.25 233.25 200.00
654 20017.09 1187604.96 4128.64
Other 0 1018.50 57776.02 0.00
-------------------------------------------------
Total 3234 57965.59 2786004.10 674308.01
Center 53
Flag Claims Units Chgs Paid
-------------------------------------------------
R 381 2005.75 83973.14 0.00
U 0 0.00 0.00 0.00
B 628 20422.50 824844.15 481.00
P 1404 10560.25 436718.68 519380.11
D 4 229.25 15250.00 0.00
S 0 1835.50 67700.75 0.00
H 0 4075.50 210599.78 210641.26
T 0 5.25 233.25 200.00
1954 21831.84 1284923.99 4328.64
Other 0 1018.50 57776.02 0.00
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Total 4371 61984.34 2982019.76 735031.01
Center 54
Flag Claims Units Chgs Paid
-------------------------------------------------
R 69 2071.75 86877.64 0.00
U 0 0.00 0.00 0.00
B 2099 22083.50 895379.08 481.00
P 2352 12275.75 507202.29 589825.84
D 40 257.75 16713.48 0.00
S 0 1835.50 67700.75 0.00
H 0 4075.50 210599.78 210641.26
T 0 5.25 233.25 200.00
500 23017.59 1355577.19 4328.64
Other 0 1018.50 57776.02 0.00
-------------------------------------------------
Total 5060 66641.09 3198059.48 805476.74
Center 55
Flag Claims Units Chgs Paid
-------------------------------------------------
R 20 2094.00 87702.39 0.00
U 0 0.00 0.00 0.00
B 272 22312.75 903630.08 481.00
P 871 13077.50 538675.54 621289.84
D 0 257.75 16713.48 0.00
S 2 1838.00 67793.25 0.00
H 0 4075.50 210599.78 210641.26
T 0 5.25 233.25 200.00
1974 24583.34 1455241.14 4328.64
Other 0 1018.50 57776.02 0.00
-------------------------------------------------
Total 3139 69262.59 3338364.93 836940.74
Center 57
Flag Claims Units Chgs Paid
-------------------------------------------------
R 187 2278.00 94595.14 0.00
U 0 0.00 0.00 0.00
B 976 23319.75 945216.08 481.00
P 1 13079.50 538749.54 621363.84
D 0 257.75 16713.48 0.00
S 0 1838.00 67793.25 0.00
H 0 4075.50 210599.78 210641.26
T 4 24.25 1183.25 1150.00
1082 27857.09 1627786.16 150806.27
Other 0 1018.50 57776.02 0.00
-------------------------------------------------
Total 2250 73748.34 3560412.70 984442.37