CMS/EIP Fiscal Report Statewide
Services beginning 04/01/2010 ending 06/30/2010 Date of Report:08/18/2010 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 12982 42183.5 1559145.00 36.96
Subtotal (Total Children Is Unduplicated) 12982 42183.5 1559145.00 36.96
----------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
AUDE-92552-PURE TONE AUDIOMETRY -AIR ONLY 11 11.00 116.82 10.62
AUDE-92553-PURE TONE AUDIOMETRY AIR & BONE 4 4.00 65.20 16.30
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 99 99.00 874.17 8.83
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 79 80.00 860.22 10.75
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 95 95.00 2070.05 21.79
AUDE-92585-AUD EVOKED RESPONSE (DIAG) 1 2.00 108.76 54.38
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 15 15.00 424.20 28.28
AUDE-92588-OTOACOUSTIC EMISSIONS (COMP) 6 7.00 222.67 31.81
BEHV-H0031HO-COMP BEHAVIORAL HEALTH ASSESSMENT 1 2.00 250.00 125.00
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 108 167.00 12525.00 75.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 34 57.00 4275.00 75.00
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 24 32.50 2437.50 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 80 124.50 9337.50 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 125 191.50 10628.25 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 1296 1838.50 137812.50 74.96
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 410 658.50 49313.00 74.89
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 394 531.00 39825.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 1538 2373.00 131591.50 55.45
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 870 1396.50 104625.00 74.92
MED-99202-OUTPATIENT VISIT, NEW, 20 MINS 2 2.00 54.44 27.22
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 140 141.00 24640.00 174.75
MED-99204-OUTPATIENT VISIT, NEW, 45 MINS 11 11.00 847.70 77.06
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 29 29.00 3045.00 105.00
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 22 26.00 1261.00 48.50
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 68 68.00 3298.00 48.50
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 19 19.00 921.50 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 85 86.00 4171.00 48.50
SCREEN-T1023-INTERDISCIPLINARY SCREENING 105 105.00 5250.00 50.00
SPCH-92506-SPEECH EVAL BY LICENSED SLP 161 163.00 7905.50 48.50
Subtotal (Total Children Is Unduplicated) 3082 8335.00 558756.48 67.04
----------------------------------------------------------------------------------------------------------------
EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 7 38.00 9475.65 249.36
AUD-92630-AUD REHAB PRELING HEARING LOSS 1 1.00 68.86 68.86
COUN-H2019HR-INDIVIDUAL/FAMILY THERAPY 1 1.00 73.42 73.42
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 30 68.00 1715.00 25.22
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 3363 24096.0 1204482.50 49.99
HERN-T1027SC-EI HEARING SERVICES AFTER SHINE 15 54.50 2725.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 638 3390.75 230096.31 67.86
OCCT-97530HM-OT SESSION BY OT ASST 37 168.50 9152.92 54.32
PHY-97110-PT SESSION BY LICENSED PT 900 4327.39 293687.51 67.87
PHY-97110HM-PT SESSION BY PT ASST 52 228.25 12398.54 54.32
SHIN-T1027SC-INITIAL SHINE SERVICES, INDIVIDUAL 29 165.50 8275.00 50.00
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 1456 7812.50 530285.05 67.88
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 21 99.50 5404.84 54.32
SPL-92508-GROUP SPL SESSION PER CHILD 17 78.25 1032.90 13.20
VISN-T1027SC-EI VISION SERVICES, INDIVIDUAL 5 36.75 1837.50 50.00
Subtotal (Total Children Is Unduplicated) 5057 40565.9 2310711.00 56.96
----------------------------------------------------------------------------------------------------------------
Total 91084.39 4428612.48 48.62
----------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 13713
----------------------------------------------------------------------------------------------------------------
Center 01
Flag Claims Units Chgs Paid
-------------------------------------------------
R 16 8.25 374.13 0.00
U 0 0.00 0.00 0.00
B 5437 3823.75 153010.00 9.25
P 2236 1540.75 58035.06 57507.75
D 73 45.50 1683.50 0.00
S 1059 841.25 36427.75 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
1128 2794.00 152797.68 1100.00
Other 1717 1841.75 115400.34 0.00
-------------------------------------------------
Total 11666 10895.25 517728.46 58617.00
Center 02
Flag Claims Units Chgs Paid
-------------------------------------------------
R 0 0.00 0.00 0.00
U 0 0.00 0.00 0.00
B 950 752.25 27417.00 0.00
P 1 0.50 18.50 0.00
D 0 0.00 0.00 0.00
S 0 0.00 0.00 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
229 363.50 20811.25 0.00
Other 0 0.00 0.00 0.00
-------------------------------------------------
Total 1180 1116.25 48246.75 0.00
Center 03
Flag Claims Units Chgs Paid
-------------------------------------------------
R 0 0.00 0.00 0.00
U 0 0.00 0.00 0.00
B 181 128.25 5924.08 0.00
P 2925 2059.75 82837.25 82726.25
D 0 0.00 0.00 0.00
S 0 0.00 0.00 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
2 2.00 135.76 0.00
Other 91 89.75 1380.77 9.25
-------------------------------------------------
Total 3199 2279.75 90277.86 82735.50
Center 04
Flag Claims Units Chgs Paid
-------------------------------------------------
R 0 0.00 0.00 0.00
U 0 0.00 0.00 0.00
B 1799 1907.50 75726.75 0.00
P 2979 2996.50 125341.25 117333.63
D 0 0.00 0.00 0.00
S 1 2.00 74.00 0.00
H 1690 5541.00 287853.58 287852.92
T 0 0.00 0.00 0.00
419 617.25 46083.63 300.00
Other 0 0.00 0.00 0.00
-------------------------------------------------
Total 6888 11064.25 535079.21 405486.55
Center 05
Flag Claims Units Chgs Paid
-------------------------------------------------
R 1 1.00 37.00 0.00
U 0 0.00 0.00 0.00
B 2871 1682.50 63504.01 0.00
P 0 0.00 0.00 0.00
D 0 0.00 0.00 0.00
S 0 0.00 0.00 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
1273 1109.50 56850.72 0.00
Other 0 0.00 0.00 0.00
-------------------------------------------------
Total 4145 2793.00 120391.73 0.00
Center 06
Flag Claims Units Chgs Paid
-------------------------------------------------
R 0 0.00 0.00 0.00
U 0 0.00 0.00 0.00
B 4207 2787.75 103146.75 18.50
P 486 317.75 11756.75 11756.75
D 0 0.00 0.00 0.00
S 0 0.00 0.00 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
3103 2702.25 157211.18 0.00
Other 0 0.00 0.00 0.00
-------------------------------------------------
Total 7796 5807.75 272114.68 11775.25
Center 07
Flag Claims Units Chgs Paid
-------------------------------------------------
R 0 0.00 0.00 0.00
U 0 0.00 0.00 0.00
B 11 8.00 296.00 0.00
P 5181 3565.75 147022.00 147022.00
D 0 0.00 0.00 0.00
S 289 145.50 5374.25 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
1331 3816.75 207828.90 0.00
Other 2 1.00 37.00 0.00
-------------------------------------------------
Total 6814 7537.00 360558.15 147022.00
Center 09
Flag Claims Units Chgs Paid
-------------------------------------------------
R 4 5.00 185.00 0.00
U 0 0.00 0.00 0.00
B 4562 4288.00 194144.86 0.00
P 117 147.00 9542.75 9542.25
D 0 0.00 0.00 0.00
S 2 3.00 195.75 0.00
H 1 1.00 50.00 50.00
T 0 0.00 0.00 0.00
1888 5225.25 319112.36 0.00
Other 0 0.00 0.00 0.00
-------------------------------------------------
Total 6574 9669.25 523230.72 9592.25
Center 10
Flag Claims Units Chgs Paid
-------------------------------------------------
R 0 0.00 0.00 0.00
U 0 0.00 0.00 0.00
B 316 205.00 7661.00 74.50
P 7941 5732.25 245681.50 245419.00
D 0 0.00 0.00 0.00
S 31 19.50 721.50 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
2144 4056.00 241492.05 0.00
Other 1 1.50 55.50 55.50
-------------------------------------------------
Total 10433 10014.25 495611.55 245549.00
Center 51
Flag Claims Units Chgs Paid
-------------------------------------------------
R 0 0.00 0.00 0.00
U 0 0.00 0.00 0.00
B 4242 2899.75 110673.21 0.00
P 0 0.00 0.00 0.00
D 0 0.00 0.00 0.00
S 0 0.00 0.00 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
1371 3266.75 193926.74 0.00
Other 0 0.00 0.00 0.00
-------------------------------------------------
Total 5613 6166.50 304599.95 0.00
Center 52
Flag Claims Units Chgs Paid
-------------------------------------------------
R 0 0.00 0.00 0.00
U 0 0.00 0.00 0.00
B 92 77.50 4542.67 0.00
P 2774 1849.00 81544.62 81535.37
D 0 0.00 0.00 0.00
S 0 0.00 0.00 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
712 1712.45 107658.96 0.00
Other 0 0.00 0.00 0.00
-------------------------------------------------
Total 3578 3638.95 193746.25 81535.37
Center 53
Flag Claims Units Chgs Paid
-------------------------------------------------
R 7 6.50 240.50 0.00
U 0 0.00 0.00 0.00
B 1712 1504.00 61416.96 0.00
P 787 947.75 49151.53 48151.53
D 2 4.00 300.00 0.00
S 0 0.00 0.00 0.00
H 0 0.00 0.00 0.00
T 1 0.75 27.75 0.00
2299 2139.25 114911.79 200.00
Other 0 0.00 0.00 0.00
-------------------------------------------------
Total 4808 4602.25 226048.53 48351.53
Center 54
Flag Claims Units Chgs Paid
-------------------------------------------------
R 5 4.00 271.52 0.00
U 0 0.00 0.00 0.00
B 2459 1908.75 81389.99 0.00
P 3023 2222.50 93017.65 92943.90
D 22 16.50 667.38 0.00
S 0 0.00 0.00 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
203 320.69 18494.13 0.00
Other 0 0.00 0.00 0.00
-------------------------------------------------
Total 5712 4472.44 193840.67 92943.90
Center 55
Flag Claims Units Chgs Paid
-------------------------------------------------
R 0 0.00 0.00 0.00
U 0 0.00 0.00 0.00
B 48 41.50 1725.00 0.00
P 1368 1296.50 50997.00 51035.50
D 0 0.00 0.00 0.00
S 5 7.50 277.50 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
2628 2167.00 140175.29 0.00
Other 0 0.00 0.00 0.00
-------------------------------------------------
Total 4049 3512.50 193174.79 51035.50
Center 57
Flag Claims Units Chgs Paid
-------------------------------------------------
R 0 0.00 0.00 0.00
U 0 0.00 0.00 0.00
B 2807 2969.00 115470.65 0.00
P 183 262.25 14504.00 14504.00
D 0 0.00 0.00 0.00
S 0 0.00 0.00 0.00
H 0 0.00 0.00 0.00
T 1 2.00 100.00 100.00
1411 4281.75 223888.53 204364.52
Other 0 0.00 0.00 0.00
-------------------------------------------------
Total 4402 7515.00 353963.18 218968.52