CMS/EIP Fiscal Report Statewide
Services beginning 01/01/2010 ending 03/31/2010 Date of Report:05/17/2010 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 11666 38255.3 1414192.25 36.97
Subtotal (Total Children Is Unduplicated) 11666 38255.3 1414192.25 36.97
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Screening, Eval, and Assessment,Class #02
AUDE-92552-PURE TONE AUDIOMETRY -AIR ONLY 2 2.00 21.24 10.62
AUDE-92553-PURE TONE AUDIOMETRY AIR & BONE 3 3.00 48.90 16.30
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 99 99.00 874.17 8.83
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 73 73.00 787.98 10.79
AUDE-92568-ACOUSTIC REFLEX TESTING (MEMR) 1 1.00 8.44 8.44
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 95 95.00 2070.05 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) 12 12.00 381.72 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 124 186.50 13987.50 75.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 44 67.00 5025.00 75.00
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 29 41.00 3075.00 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 88 150.50 11287.50 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 111 165.50 9185.25 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 1157 1618.50 121350.00 74.98
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 387 599.50 44962.50 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 319 421.50 31612.50 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 1418 2163.00 120046.50 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 779 1226.50 91958.25 74.98
MED-99202-OUTPATIENT VISIT, NEW, 20 MINS 1 1.00 27.22 27.22
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 128 128.00 22957.50 179.36
MED-99204-OUTPATIENT VISIT, NEW, 45 MINS 5 5.00 504.08 100.82
MED-99205-OUTPATIENT VISIT, NEW, 60 MINS 6 6.00 436.68 72.78
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 19 19.00 1995.00 105.00
MED-99215-OUTPATIENT VISIT, EST, 40 MINS 6 6.00 300.90 50.15
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 24 24.00 1164.00 48.50
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 75 76.00 3686.00 48.50
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 26 26.00 1261.00 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 57 58.00 2813.00 48.50
SCREEN-T1023-INTERDISCIPLINARY SCREENING 110 124.00 6150.50 49.60
SPCH-92506-SPEECH EVAL BY LICENSED SLP 183 189.53 9192.21 48.50
Subtotal (Total Children Is Unduplicated) 2858 7597.03 507628.41 66.82
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 4 9.00 9515.07 1057.23
AUD-92630-AUD REHAB PRELING HEARING LOSS 1 3.00 206.58 68.86
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 13 52.00 1300.00 25.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 2978 19654.0 982675.00 50.00
HERN-T1027SC-EI HEARING SERVICES AFTER SHINE 10 38.00 1900.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 623 3260.50 221062.16 67.80
OCCT-97530HM-OT SESSION BY OT ASST 30 111.50 6056.68 54.32
PHY-97110-PT SESSION BY LICENSED PT 843 3946.00 267854.48 67.88
PHY-97110HM-PT SESSION BY PT ASST 41 193.00 10483.76 54.32
SENS-V5264-EARMOLD 1 2.00 37.44 18.72
SHIN-T1027SC-INITIAL SHINE SERVICES, INDIVIDUAL 15 23.00 1150.00 50.00
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 1327 6656.72 451783.13 67.87
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 19 32.00 1738.24 54.32
SPL-92508-GROUP SPL SESSION PER CHILD 19 72.00 950.40 13.20
VISN-T1027SC-EI VISION SERVICES, INDIVIDUAL 3 26.25 1312.50 50.00
Subtotal (Total Children Is Unduplicated) 4579 34079.0 1958025.44 57.46
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Total 79931.25 3879846.10 48.54
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Number of Children (Unduplicated) With at Least One Service 12475
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Center 01
Flag Claims Units Chgs Paid
-------------------------------------------------
R 37 22.50 832.50 0.00
U 0 0.00 0.00 0.00
B 1945 1272.25 49395.75 277.50
P 3983 2853.75 110218.04 109515.75
D 146 97.50 3607.50 0.00
S 839 605.50 22501.25 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
927 2169.50 117032.88 371.52
Other 1486 1874.75 116770.02 92.50
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Total 9363 8895.75 420357.94 110257.27
Center 02
Flag Claims Units Chgs Paid
-------------------------------------------------
R 18 35.00 1295.00 0.00
U 0 0.00 0.00 0.00
B 811 1940.50 73936.00 277.50
P 2 2854.75 110255.04 109515.75
D 0 97.50 3607.50 0.00
S 0 605.50 22501.25 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
98 2333.25 126347.88 371.52
Other 0 1874.75 116770.02 92.50
-------------------------------------------------
Total 929 9741.25 454712.69 110257.27
Center 03
Flag Claims Units Chgs Paid
-------------------------------------------------
R 11 48.25 1861.25 0.00
U 0 0.00 0.00 0.00
B 243 2146.75 81709.00 342.25
P 2608 4870.75 191777.79 190807.25
D 0 97.50 3607.50 0.00
S 0 605.50 22501.25 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
65 2424.00 131048.13 371.52
Other 85 1959.75 118097.38 92.50
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Total 3012 12152.50 550602.30 191613.52
Center 04
Flag Claims Units Chgs Paid
-------------------------------------------------
R 1 50.25 1935.25 0.00
U 0 0.00 0.00 0.00
B 4030 6152.50 240181.00 342.25
P 636 5551.00 218634.68 216276.46
D 0 97.50 3607.50 0.00
S 0 605.50 22501.25 0.00
H 1136 3519.00 182750.80 183286.44
T 0 0.00 0.00 0.00
434 3127.75 186607.78 571.52
Other 0 1959.75 118097.38 92.50
-------------------------------------------------
Total 6237 21063.25 974315.64 400569.17
Center 05
Flag Claims Units Chgs Paid
-------------------------------------------------
R 78 92.50 3498.50 0.00
U 0 0.00 0.00 0.00
B 2595 7581.00 293081.75 342.25
P 0 5551.00 218634.68 216276.46
D 0 97.50 3607.50 0.00
S 0 605.50 22501.25 0.00
H 0 3519.00 182750.80 183286.44
T 0 0.00 0.00 0.00
1432 4320.75 250841.63 571.52
Other 0 1959.75 118097.38 92.50
-------------------------------------------------
Total 4105 23727.00 1093013.49 400569.17
Center 06
Flag Claims Units Chgs Paid
-------------------------------------------------
R 0 92.50 3498.50 0.00
U 0 0.00 0.00 0.00
B 1646 8614.50 331321.25 573.50
P 2932 7473.25 289757.93 287399.71
D 0 97.50 3607.50 0.00
S 0 605.50 22501.25 0.00
H 0 3519.00 182750.80 183286.44
T 0 0.00 0.00 0.00
3024 6952.25 406146.61 571.52
Other 0 1959.75 118097.38 92.50
-------------------------------------------------
Total 7602 29314.25 1357681.22 471923.67
Center 07
Flag Claims Units Chgs Paid
-------------------------------------------------
R 3 94.50 3572.50 0.00
U 0 0.00 0.00 0.00
B 92 8668.00 333370.75 573.50
P 5031 10761.75 424105.43 421634.71
D 0 97.50 3607.50 0.00
S 101 662.50 24601.00 0.00
H 0 3519.00 182750.80 183286.44
T 0 0.00 0.00 0.00
1261 10558.25 603534.43 571.52
Other 0 1959.75 118097.38 92.50
-------------------------------------------------
Total 6488 36321.25 1693639.79 606158.67
Center 09
Flag Claims Units Chgs Paid
-------------------------------------------------
R 8 101.25 3859.25 0.00
U 0 0.00 0.00 0.00
B 3189 11479.50 460250.04 573.50
P 524 11350.00 455693.98 453223.26
D 0 97.50 3607.50 0.00
S 0 662.50 24601.00 0.00
H 1 3520.00 182825.80 183361.44
T 0 0.00 0.00 0.00
1671 14986.00 872850.22 571.52
Other 3 1961.75 118171.38 92.50
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Total 5396 44158.50 2121859.17 637822.22
Center 10
Flag Claims Units Chgs Paid
-------------------------------------------------
R 3 102.75 3914.75 0.00
U 0 0.00 0.00 0.00
B 1548 12442.75 496354.04 712.25
P 7192 16596.25 687405.48 684490.27
D 0 97.50 3607.50 0.00
S 78 716.50 26599.00 0.00
H 0 3520.00 182825.80 183361.44
T 0 0.00 0.00 0.00
1489 18063.50 1056263.75 571.52
Other 0 1961.75 118171.38 92.50
-------------------------------------------------
Total 10310 53501.00 2575141.70 869227.98
Center 51
Flag Claims Units Chgs Paid
-------------------------------------------------
R 19 122.75 4654.75 0.00
U 0 0.00 0.00 0.00
B 3886 15281.25 602233.79 712.25
P 0 16596.25 687405.48 684490.27
D 0 97.50 3607.50 0.00
S 0 716.50 26599.00 0.00
H 0 3520.00 182825.80 183361.44
T 0 0.00 0.00 0.00
1254 21047.50 1243928.67 571.52
Other 1 1962.50 118199.13 92.50
-------------------------------------------------
Total 5160 59344.25 2869454.12 869227.98
Center 52
Flag Claims Units Chgs Paid
-------------------------------------------------
R 0 122.75 4654.75 0.00
U 0 0.00 0.00 0.00
B 2046 16670.50 665788.75 712.25
P 805 17065.25 704780.11 701864.90
D 0 97.50 3607.50 0.00
S 1 719.75 26719.25 0.00
H 0 3520.00 182825.80 183361.44
T 0 0.00 0.00 0.00
717 22703.25 1347605.60 571.52
Other 0 1962.50 118199.13 92.50
-------------------------------------------------
Total 3569 62861.50 3054180.89 886602.61
Center 53
Flag Claims Units Chgs Paid
-------------------------------------------------
R 53 219.75 10001.75 0.00
U 0 0.00 0.00 0.00
B 333 17033.25 682439.50 712.25
P 782 17917.25 747568.28 744652.82
D 0 97.50 3607.50 0.00
S 0 719.75 26719.25 0.00
H 0 3520.00 182825.80 183361.44
T 0 0.00 0.00 0.00
2117 24665.50 1451605.86 970.02
Other 1 1963.50 118249.13 92.50
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Total 3286 66136.50 3223017.07 929789.03
Center 54
Flag Claims Units Chgs Paid
-------------------------------------------------
R 3 224.25 10314.25 0.00
U 0 0.00 0.00 0.00
B 5055 20895.00 843428.96 712.25
P 253 18117.25 757986.32 755002.98
D 30 115.00 4382.27 0.00
S 2 720.50 26747.00 0.00
H 0 3520.00 182825.80 183361.44
T 1 0.25 9.25 0.00
111 24957.75 1467478.60 970.02
Other 2 1964.75 118295.38 92.50
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Total 5457 70514.75 3411467.83 940139.19
Center 55
Flag Claims Units Chgs Paid
-------------------------------------------------
R 0 224.25 10314.25 0.00
U 0 0.00 0.00 0.00
B 5 20899.50 843595.46 712.25
P 1361 19392.00 808234.57 805213.73
D 0 115.00 4382.27 0.00
S 1 721.00 26765.50 0.00
H 0 3520.00 182825.80 183361.44
T 0 0.25 9.25 0.00
2573 26995.75 1598314.33 970.02
Other 0 1964.75 118295.38 92.50
-------------------------------------------------
Total 3940 73832.50 3592736.81 990349.94
Center 57
Flag Claims Units Chgs Paid
-------------------------------------------------
R 167 357.25 15235.25 0.00
U 0 0.00 0.00 0.00
B 1436 22406.25 902919.96 712.25
P 927 20402.00 850242.57 847221.73
D 0 115.00 4382.27 0.00
S 3 726.00 27051.26 217.88
H 0 3520.00 182825.80 183361.44
T 1 3.25 159.25 150.00
1154 30436.75 1778734.36 162517.94
Other 0 1964.75 118295.38 92.50
-------------------------------------------------
Total 3688 79931.25 3879846.10 1194273.74