CMS/EIP Fiscal Report Statewide
Services beginning 07/01/2010 ending 09/30/2010 Date of Report:11/17/2010 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 12988 42709.75000 1578948.2500 36.9693
Subtotal (Total Children Is Unduplicated) 12988 42709.75000 1578948.2500 36.9693
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Screening, Eval, and Assessment,Class #02
AUDE-92552-PURE TONE AUDIOMETRY -AIR ONLY 5 5.000000 53.1000 10.6200
AUDE-92553-PURE TONE AUDIOMETRY AIR & BONE 2 2.000000 32.1600 16.0800
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 92 93.000000 814.5900 8.7590
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 71 73.000000 786.3000 10.7712
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 91 91.000000 1986.7900 21.8329
AUDE-92585-AUD EVOKED RESPONSE (DIAG) 3 3.000000 162.0400 54.0133
AUDE-92586-AUD EVOKED RESPONSE (SCREEN) 1 1.000000 30.4300 30.4300
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 18 18.000000 509.0400 28.2800
AUDE-92588-OTOACOUSTIC EMISSIONS (COMP) 10 10.000000 315.2000 31.5200
BEHV-H0031HO-COMP BEHAVIORAL HEALTH ASSESSMENT 8 11.000000 1375.0000 125.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 124 200.000000 15000.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 31 40.500000 3037.5000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 33 42.500000 3112.5000 73.2353
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 75 114.500000 8587.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 135 210.000000 11619.0000 55.3286
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 1410 2024.000000 151725.0000 74.9629
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 412 625.000000 46875.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 468 648.000000 48487.5000 74.8264
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 1607 2535.000000 140581.5000 55.4562
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 1002 1615.000000 121012.5000 74.9303
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 126 126.000000 22587.5000 179.2659
MED-99204-OUTPATIENT VISIT, NEW, 45 MINS 4 4.000000 229.0800 57.2700
MED-99205-OUTPATIENT VISIT, NEW, 60 MINS 6 6.000000 436.6800 72.7800
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 24 24.000000 2520.0000 105.0000
MED-99215-OUTPATIENT VISIT, EST, 40 MINS 8 8.000000 401.2000 50.1500
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 30 30.000000 1455.0000 48.5000
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 69 75.000000 3637.5000 48.5000
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 19 19.000000 921.5000 48.5000
PSTH-97001-EVAL BY LICENSED PT, INITIAL 93 97.000000 4704.5000 48.5000
SCREEN-T1023-INTERDISCIPLINARY SCREENING 91 91.000000 4550.0000 50.0000
SPCH-92506-SPEECH EVAL BY LICENSED SLP 207 211.000000 10233.5000 48.5000
Subtotal (Total Children Is Unduplicated) 3237 9052.500000 607779.1100 67.1394
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 2 2.000000 488.8300 244.4150
AUD-92630-AUD REHAB PRELING HEARING LOSS 2 4.000000 283.6900 70.9225
COUN-H2019HR-INDIVIDUAL/FAMILY THERAPY 1 9.000000 660.7800 73.4200
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 34 120.000000 3000.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 3661 26134.25000 1306514.5000 49.9924
HERN-T1027SC-EI HEARING SERVICES AFTER SHINE 19 64.000000 3200.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 704 3535.250000 239915.3300 67.8638
OCCT-97530HM-OT SESSION BY OT ASST 60 280.500000 15207.5800 54.2160
PHY-97110-PT SESSION BY LICENSED PT 1014 4790.750000 324152.2400 67.6621
PHY-97110HM-PT SESSION BY PT ASST 34 145.250000 7889.9800 54.3200
SENS-V5264-EARMOLD 1 1.000000 18.0000 18.0000
SHIN-T1027SC-INITIAL SHINE SERVICES, INDIVIDUAL 13 52.000000 2600.0000 50.0000
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 1644 8784.750000 596159.3200 67.8630
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 28 141.000000 7659.1200 54.3200
SPL-92508-GROUP SPL SESSION PER CHILD 31 75.750000 999.9000 13.2000
VISN-T1027SC-EI VISION SERVICES, INDIVIDUAL 5 24.000000 1200.0000 50.0000
Subtotal (Total Children Is Unduplicated) 5507 44163.50000 2509949.2700 56.8331
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Total 95925.750000 4696676.6300 48.9616
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Number of Children (Unduplicated) With at Least One Service 13767
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Center 01
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 920 653.500000 28005.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 5900 4339.750000 175698.2500 0.0000
P 1303 984.000000 43136.5700 40894.0000
D 42 22.000000 890.0000 0.0000
S 174 111.500000 4396.5000 0.0000
H 0 0.000000 0.0000 0.0000
T 1 2.000000 74.0000 0.0000
1511 3419.500000 186233.9100 0.0000
Other 1135 1273.250000 79376.8500 0.0000
---------------------------------------------------------
Total 10986 10805.500000 517811.0800 40894.0000
Center 02
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 6 4.000000 148.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 738 547.000000 20155.7500 0.0000
P 2 1.000000 37.0000 0.0000
D 0 0.000000 0.0000 0.0000
S 4 2.250000 83.2500 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
322 528.250000 28829.7500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 1072 1082.500000 49253.7500 0.0000
Center 03
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 15 12.500000 462.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 219 149.000000 5665.0000 9.2500
P 2800 1890.000000 75092.7700 75087.0200
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
0 0.000000 0.0000 0.0000
Other 84 83.250000 1374.8000 0.0000
---------------------------------------------------------
Total 3118 2134.750000 82595.0700 75096.2700
Center 04
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 1 0.750000 27.7500 0.0000
U 0 0.000000 0.0000 0.0000
B 1944 2024.750000 78354.7500 0.0000
P 2657 2754.000000 109538.5000 106617.0200
D 45 45.000000 8005.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 1793 5730.750000 296210.0100 295995.5900
T 0 0.000000 0.0000 0.0000
415 708.000000 52553.1200 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 6855 11263.250000 544689.1300 402612.6100
Center 05
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 2991 1758.250000 67368.9500 0.0000
P 33 39.000000 2775.0000 2775.0000
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
1192 949.750000 48110.2000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 4216 2747.000000 118254.1500 2775.0000
Center 06
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 11 5.750000 212.7500 0.0000
U 0 0.000000 0.0000 0.0000
B 4223 2825.250000 104515.7500 0.0000
P 65 42.750000 1581.7500 1581.7500
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
3866 3254.500000 186645.6800 0.0000
Other 1 0.500000 18.5000 0.0000
---------------------------------------------------------
Total 8166 6128.750000 292974.4300 1581.7500
Center 07
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 99 84.750000 3135.7500 0.0000
U 0 0.000000 0.0000 0.0000
B 2294 1564.500000 63153.7500 0.0000
P 2456 1603.750000 65727.2500 61493.2500
D 19 30.500000 2237.5000 0.0000
S 33 25.250000 934.2500 0.0000
H 0 0.000000 0.0000 0.0000
T 1 1.000000 37.0000 0.0000
1404 4226.500000 228909.3200 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 6306 7536.250000 364134.8200 61493.2500
Center 09
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 12 11.500000 462.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 5712 5741.000000 260479.2800 0.0000
P 482 420.000000 16375.4000 16375.4700
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
1840 5084.000000 310439.2600 0.0000
Other 2 1.500000 55.5000 0.0000
---------------------------------------------------------
Total 8048 11258.000000 587811.9400 16375.4700
Center 10
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 19 9.000000 333.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 423 250.750000 9409.7500 0.0000
P 7907 5545.000000 237935.2500 237935.2500
D 0 0.000000 0.0000 0.0000
S 112 71.250000 2636.2500 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
2230 4532.000000 266435.7300 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 10691 10408.000000 516749.9800 237935.2500
Center 51
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 4 3.250000 120.2500 0.0000
U 0 0.000000 0.0000 0.0000
B 4237 3012.250000 113893.9000 0.0000
P 2 1.500000 93.5000 0.0000
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
1309 3271.750000 194622.3900 0.0000
Other 1 0.500000 18.5000 0.0000
---------------------------------------------------------
Total 5553 6289.250000 308748.5400 0.0000
Center 52
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 20 10.750000 546.1500 0.0000
P 2822 1975.750000 90075.8100 89850.8100
D 0 0.000000 0.0000 0.0000
S 17 9.750000 391.6300 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
611 1481.750000 92793.9000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 3470 3478.000000 183807.4900 89850.8100
Center 53
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 97 107.500000 4255.5000 311.0000
U 0 0.000000 0.0000 0.0000
B 1346 1296.000000 54015.7500 0.0000
P 699 834.000000 41830.5000 40180.5000
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
2459 2403.500000 131487.7800 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 4601 4641.000000 231589.5300 40491.5000
Center 54
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 25 18.250000 760.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 3189 2353.500000 98726.0800 0.0000
P 2454 1791.500000 75385.4300 75262.8000
D 13 7.000000 272.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
1148 2783.750000 161841.3100 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 6829 6954.000000 336984.8200 75262.8000
Center 55
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 15 11.250000 416.2500 0.0000
U 0 0.000000 0.0000 0.0000
B 41 50.250000 3227.2500 0.0000
P 1616 1482.000000 57091.7500 57082.5000
D 0 0.000000 0.0000 0.0000
S 4 5.250000 194.2500 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
2710 2259.250000 146473.6900 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 4386 3808.000000 207403.1900 57082.5000
Center 57
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 16 19.500000 721.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 2815 3053.250000 126605.2500 0.0000
P 1 2.000000 74.0000 74.0000
D 0 0.000000 0.0000 0.0000
S 4 7.500000 401.8200 401.8200
H 0 0.000000 0.0000 0.0000
T 1 5.000000 250.0000 250.0000
1450 4304.250000 225816.1400 223048.7700
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 4287 7391.500000 353868.7100 223774.5900