CMS/EIP Fiscal Report Statewide
Services beginning 07/01/2008 ending 09/30/2008 Date of Report:11/18/2008 Page: 1
Payclass Filters:TPIN
Eligibility Filter:Not Part C
List order: No List
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
CASE-CASE-NON-TCM CASE MANAGEMENT 2 0.50 18.50 37.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 4 4.25 157.25 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 12 33.25 1230.25 37.00
Subtotal (Total Children Is Unduplicated) 12 38.00 1406.00 37.00
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Screening, Eval, and Assessment,Class #02
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 25 25.00 220.75 8.83
AUDE-92557-COMP AUDIO THRESHOLD EVAL/SPCH RECOG 1 1.00 27.10 27.10
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 21 21.00 226.80 10.80
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 27 27.00 588.33 21.79
EVAL-EVAL-DEVELOPMENTAL EVALUATION 1 1.50 75.00 50.00
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 10 12.50 937.50 75.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 3 4.00 487.50 121.88
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 3 3.00 225.00 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 1 1.50 83.25 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 113 153.00 11342.50 74.13
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 29 40.50 3037.50 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 49 60.50 4431.50 73.25
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 71 104.00 5772.00 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 47 59.50 4462.50 75.00
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 1 1.00 185.00 185.00
MED-99204-OUTPATIENT VISIT, NEW, 45 MINS 1 1.00 57.27 57.27
SCREEN-T1023-INTERDISCIPLINARY SCREENING 4 4.00 200.00 50.00
Subtotal (Total Children Is Unduplicated) 193 520.00 32359.50 62.23
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EI Services,Class #03
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 2 2.00 247.83 123.92
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 1 20.00 10.00 0.50
Subtotal (Total Children Is Unduplicated) 3 22.00 257.83 11.72
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Total 580.00 34023.33 58.66
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Number of Children (Unduplicated) With at Least One Service 206
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Center 01
Flag Claims Units Chgs Paid
-------------------------------------------------
R 0 0.00 0.00 0.00
U 0 0.00 0.00 0.00
B 0 0.00 0.00 0.00
P 0 0.00 0.00 0.00
D 0 0.00 0.00 0.00
S 3 3.50 129.50 0.00
H 10 11.50 813.75 0.00
T 17 23.00 1559.25 1559.25
30 24.25 1040.20 0.00
Other 14 20.50 1342.50 0.00
-------------------------------------------------
Total 74 82.75 4885.20 1559.25
Center 02
Flag Claims Units Chgs Paid
-------------------------------------------------
R 0 0.00 0.00 0.00
U 0 0.00 0.00 0.00
B 0 0.00 0.00 0.00
P 0 0.00 0.00 0.00
D 0 0.00 0.00 0.00
S 0 3.50 129.50 0.00
H 0 11.50 813.75 0.00
T 0 23.00 1559.25 1559.25
6 30.75 1280.70 0.00
Other 0 20.50 1342.50 0.00
-------------------------------------------------
Total 6 89.25 5125.70 1559.25
Center 03
Flag Claims Units Chgs Paid
-------------------------------------------------
R 0 0.00 0.00 0.00
U 0 0.00 0.00 0.00
B 0 0.00 0.00 0.00
P 0 0.00 0.00 0.00
D 0 0.00 0.00 0.00
S 0 3.50 129.50 0.00
H 0 11.50 813.75 0.00
T 0 23.00 1559.25 1559.25
0 30.75 1280.70 0.00
Other 20 40.50 1646.96 0.00
-------------------------------------------------
Total 20 109.25 5430.16 1559.25
Center 04
Flag Claims Units Chgs Paid
-------------------------------------------------
R 0 0.00 0.00 0.00
U 0 0.00 0.00 0.00
B 0 0.00 0.00 0.00
P 1 1.00 185.00 309.29
D 0 0.00 0.00 0.00
S 0 3.50 129.50 0.00
H 0 11.50 813.75 0.00
T 0 23.00 1559.25 1559.25
0 30.75 1280.70 0.00
Other 0 40.50 1646.96 0.00
-------------------------------------------------
Total 1 110.25 5615.16 1868.54
Center 05
Flag Claims Units Chgs Paid
-------------------------------------------------
R 0 0.00 0.00 0.00
U 0 0.00 0.00 0.00
B 0 0.00 0.00 0.00
P 0 1.00 185.00 309.29
D 0 0.00 0.00 0.00
S 0 3.50 129.50 0.00
H 0 11.50 813.75 0.00
T 0 23.00 1559.25 1559.25
10 42.75 2173.58 0.00
Other 0 40.50 1646.96 0.00
-------------------------------------------------
Total 10 122.25 6508.04 1868.54
Center 06
Flag Claims Units Chgs Paid
-------------------------------------------------
R 0 0.00 0.00 0.00
U 0 0.00 0.00 0.00
B 0 0.00 0.00 0.00
P 0 1.00 185.00 309.29
D 0 0.00 0.00 0.00
S 0 3.50 129.50 0.00
H 0 11.50 813.75 0.00
T 0 23.00 1559.25 1559.25
93 142.75 6364.37 0.00
Other 0 40.50 1646.96 0.00
-------------------------------------------------
Total 93 222.25 10698.83 1868.54
Center 09
Flag Claims Units Chgs Paid
-------------------------------------------------
R 0 0.00 0.00 0.00
U 0 0.00 0.00 0.00
B 0 0.00 0.00 0.00
P 0 1.00 185.00 309.29
D 0 0.00 0.00 0.00
S 0 3.50 129.50 0.00
H 0 11.50 813.75 0.00
T 0 23.00 1559.25 1559.25
98 253.25 14236.87 0.00
Other 0 40.50 1646.96 0.00
-------------------------------------------------
Total 98 332.75 18571.33 1868.54
Center 10
Flag Claims Units Chgs Paid
-------------------------------------------------
R 0 0.00 0.00 0.00
U 0 0.00 0.00 0.00
B 0 0.00 0.00 0.00
P 0 1.00 185.00 309.29
D 0 0.00 0.00 0.00
S 0 3.50 129.50 0.00
H 0 11.50 813.75 0.00
T 0 23.00 1559.25 1559.25
76 376.75 22719.37 0.00
Other 0 40.50 1646.96 0.00
-------------------------------------------------
Total 76 456.25 27053.83 1868.54
Center 52
Flag Claims Units Chgs Paid
-------------------------------------------------
R 0 0.00 0.00 0.00
U 0 0.00 0.00 0.00
B 0 0.00 0.00 0.00
P 0 1.00 185.00 309.29
D 0 0.00 0.00 0.00
S 0 3.50 129.50 0.00
H 19 39.00 2557.50 0.00
T 0 23.00 1559.25 1559.25
21 420.75 24134.87 0.00
Other 0 40.50 1646.96 0.00
-------------------------------------------------
Total 40 527.75 30213.08 1868.54
Center 54
Flag Claims Units Chgs Paid
-------------------------------------------------
R 0 0.00 0.00 0.00
U 0 0.00 0.00 0.00
B 0 0.00 0.00 0.00
P 0 1.00 185.00 309.29
D 0 0.00 0.00 0.00
S 0 3.50 129.50 0.00
H 0 39.00 2557.50 0.00
T 0 23.00 1559.25 1559.25
22 442.00 25696.62 0.00
Other 0 40.50 1646.96 0.00
-------------------------------------------------
Total 22 549.00 31774.83 1868.54
Center 55
Flag Claims Units Chgs Paid
-------------------------------------------------
R 0 0.00 0.00 0.00
U 0 0.00 0.00 0.00
B 0 0.00 0.00 0.00
P 0 1.00 185.00 309.29
D 0 0.00 0.00 0.00
S 0 3.50 129.50 0.00
H 0 39.00 2557.50 0.00
T 0 23.00 1559.25 1559.25
16 473.00 27945.12 0.00
Other 0 40.50 1646.96 0.00
-------------------------------------------------
Total 16 580.00 34023.33 1868.54