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:Part C (excluding not eligible)
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 9 5.00 185.00 37.00
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 4 4.00 262.50 65.63
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 20 20.75 767.75 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 139 284.25 10461.75 36.80
Subtotal (Total Children Is Unduplicated) 142 314.00 11677.00 37.19
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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) 145 145.00 1280.35 8.83
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 128 129.00 1392.78 10.80
AUDE-92568-ACOUSTIC REFLEX TESTING (MEMR) 3 3.00 25.32 8.44
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 141 141.00 3072.39 21.79
AUDE-92585-AUD EVOKED RESPONSE (DIAG) 1 1.00 54.38 54.38
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 17 17.00 480.76 28.28
AUDE-92588-OTOACOUSTIC EMISSIONS (COMP) 7 7.00 222.67 31.81
AUDE-V5090-DISPENSING FEE PER HEARING AID 2 4.00 478.40 119.60
EVAL-EVAL-DEVELOPMENTAL EVALUATION 17 25.50 1275.00 50.00
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 60 88.50 6637.50 75.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 8 9.00 675.00 75.00
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 19 21.50 1612.50 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 46 74.00 5887.50 79.56
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 16 24.00 1332.00 55.50
IPDEI-IPDEI_NM-INITIAL PSYCH & DEV EVAL BY NON-MED PR 1 1.50 83.25 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 391 578.37 43155.54 74.62
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 126 202.00 15584.50 77.15
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 171 242.61 17968.00 74.06
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 152 238.00 13209.00 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 131 182.50 14325.00 78.49
MED-99202-OUTPATIENT VISIT, NEW, 20 MINS 6 6.00 163.32 27.22
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 7 7.00 1295.00 185.00
MED-99204-OUTPATIENT VISIT, NEW, 45 MINS 20 20.00 1363.13 68.16
MED-99205-OUTPATIENT VISIT, NEW, 60 MINS 2 2.00 145.56 72.78
MED-99212-OUTPATIENT VISIT, EST, 10 MINS 1 1.00 18.17 18.17
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 2 2.00 210.00 105.00
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 10 9.20 446.50 48.53
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 35 38.85 2140.64 55.10
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 8 8.00 388.00 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 28 28.00 1358.00 48.50
SCREEN-T1023-INTERDISCIPLINARY SCREENING 3 3.00 150.00 50.00
SPCH-92506-SPEECH EVAL BY LICENSED SLP 76 77.00 4090.87 53.13
Subtotal (Total Children Is Unduplicated) 828 2340.53 140569.19 60.06
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 1 2.00 69.82 34.91
AUD-HA_FUP-AUDIOLOGY SERVICES 1 1.00 50.00 50.00
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 3 3.50 175.00 50.00
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 1 1.00 50.00 50.00
CONOF-CONOF-CONSULT, OT, FACE TO FACE 3 2.50 125.00 50.00
CONPF-CONPF-CONSULT, PT, FACE TO FACE 4 3.50 165.00 47.14
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 6 6.00 300.00 50.00
CONSP-CONSP-CONSULT, SLP, PHONE 1 1.00 25.00 25.00
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 1 1.00 25.00 25.00
EIIF-EIIF_NM-EI INDIVIDUAL SESSION BY NONMED PROF 1 1.00 50.00 50.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 102 419.45 26334.90 62.78
OCCT-97530-OT SESSION BY LICENSED OT 609 2649.36 185199.06 69.90
OCCT-97530HM-OT SESSION BY OT ASST 28 63.50 3555.68 55.99
PHY-97110-PT SESSION BY LICENSED PT 622 2372.31 162141.06 68.35
PHY-97110HM-PT SESSION BY PT ASST 15 51.19 2828.44 55.25
SENS-HA_EIP-ONE UNIT UP TO $500 PER AID 1 2.00 1000.00 500.00
SENS-V5050-MED HEARING AID - ANALOG/DIGITAL 1 2.00 474.24 237.12
SENS-V5264-EARMOLD 3 7.00 131.04 18.72
SHIN-T1027SC-INITIAL SHINE SERVICES, INDIVIDUAL 1 1.50 75.00 50.00
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 1048 4083.91 278067.18 68.09
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 13 27.50 1493.80 54.32
SPL-92508-GROUP SPL SESSION PER CHILD 24 57.25 842.50 14.72
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 10 299.00 149.50 0.50
Subtotal (Total Children Is Unduplicated) 1749 10058.5 663327.22 65.95
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Total 12713.00 815573.41 64.15
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Number of Children (Unduplicated) With at Least One Service 2397
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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 4 12.25 2087.73 1929.48
D 0 0.00 0.00 0.00
S 4 4.00 148.00 0.00
H 21 26.00 1667.75 0.00
T 32 45.00 2954.42 2954.42
460 481.25 24215.57 0.00
Other 110 211.75 8260.35 0.00
-------------------------------------------------
Total 631 780.25 39333.82 4883.90
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 12.25 2087.73 1929.48
D 0 0.00 0.00 0.00
S 0 4.00 148.00 0.00
H 0 26.00 1667.75 0.00
T 0 45.00 2954.42 2954.42
72 547.25 27057.07 0.00
Other 0 211.75 8260.35 0.00
-------------------------------------------------
Total 72 846.25 42175.32 4883.90
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 12.25 2087.73 1929.48
D 0 0.00 0.00 0.00
S 0 4.00 148.00 0.00
H 0 26.00 1667.75 0.00
T 0 45.00 2954.42 2954.42
0 547.25 27057.07 0.00
Other 63 274.75 9210.23 0.00
-------------------------------------------------
Total 63 909.25 43125.20 4883.90
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 17 29.75 4261.98 5454.03
D 8 17.00 1120.06 1153.96
S 0 4.00 148.00 0.00
H 53 152.87 9753.27 8094.74
T 0 45.00 2954.42 2954.42
2 549.25 27207.07 0.00
Other 0 274.75 9210.23 0.00
-------------------------------------------------
Total 80 1072.62 54655.03 17657.15
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 29.75 4261.98 5454.03
D 0 17.00 1120.06 1153.96
S 0 4.00 148.00 0.00
H 0 152.87 9753.27 8094.74
T 0 45.00 2954.42 2954.42
1995 1632.75 99878.42 0.00
Other 0 274.75 9210.23 0.00
-------------------------------------------------
Total 1995 2156.12 127326.38 17657.15
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 29.75 4261.98 5454.03
D 0 17.00 1120.06 1153.96
S 0 4.00 148.00 0.00
H 0 152.87 9753.27 8094.74
T 0 45.00 2954.42 2954.42
2297 3553.75 213568.22 0.00
Other 0 274.75 9210.23 0.00
-------------------------------------------------
Total 2297 4077.12 241016.18 17657.15
Center 07
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 29.75 4261.98 5454.03
D 0 17.00 1120.06 1153.96
S 0 4.00 148.00 0.00
H 0 152.87 9753.27 8094.74
T 0 45.00 2954.42 2954.42
27 3622.00 218105.63 0.00
Other 0 274.75 9210.23 0.00
-------------------------------------------------
Total 27 4145.37 245553.59 17657.15
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 27 67.25 6788.10 10760.74
D 0 17.00 1120.06 1153.96
S 0 4.00 148.00 0.00
H 0 152.87 9753.27 8094.74
T 0 45.00 2954.42 2954.42
1680 6361.25 405737.87 1938.00
Other 0 274.75 9210.23 0.00
-------------------------------------------------
Total 1707 6922.12 435711.95 24901.86
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 1 68.75 6889.92 10760.74
D 0 17.00 1120.06 1153.96
S 0 4.00 148.00 0.00
H 0 152.87 9753.27 8094.74
T 0 45.00 2954.42 2954.42
1027 8071.00 521656.72 1938.00
Other 0 274.75 9210.23 0.00
-------------------------------------------------
Total 1028 8633.37 551732.62 24901.86
Center 51
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 68.75 6889.92 10760.74
D 0 17.00 1120.06 1153.96
S 0 4.00 148.00 0.00
H 0 152.87 9753.27 8094.74
T 0 45.00 2954.42 2954.42
144 8416.50 541766.52 1938.00
Other 0 274.75 9210.23 0.00
-------------------------------------------------
Total 144 8978.87 571842.42 24901.86
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 1 70.75 7025.68 10760.74
D 0 17.00 1120.06 1153.96
S 0 4.00 148.00 0.00
H 60 249.62 15971.60 8094.74
T 0 45.00 2954.42 2954.42
656 9678.82 620765.34 1938.00
Other 0 274.75 9210.23 0.00
-------------------------------------------------
Total 717 10339.94 657195.33 24901.86
Center 53
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 70.75 7025.68 10760.74
D 0 17.00 1120.06 1153.96
S 0 4.00 148.00 0.00
H 0 249.62 15971.60 8094.74
T 0 45.00 2954.42 2954.42
267 9937.11 634718.35 1938.00
Other 0 274.75 9210.23 0.00
-------------------------------------------------
Total 267 10598.23 671148.34 24901.86
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 16 87.00 11332.28 13269.56
D 0 17.00 1120.06 1153.96
S 1 5.00 383.80 0.00
H 0 249.62 15971.60 8094.74
T 0 45.00 2954.42 2954.42
564 10920.34 700205.35 1938.00
Other 0 274.75 9210.23 0.00
-------------------------------------------------
Total 581 11598.71 741177.74 27410.68
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 87.00 11332.28 13269.56
D 0 17.00 1120.06 1153.96
S 0 5.00 383.80 0.00
H 0 249.62 15971.60 8094.74
T 0 45.00 2954.42 2954.42
1060 11623.13 747323.42 1938.00
Other 0 274.75 9210.23 0.00
-------------------------------------------------
Total 1060 12301.50 788295.81 27410.68
Center 57
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 87.00 11332.28 13269.56
D 0 17.00 1120.06 1153.96
S 0 5.00 383.80 0.00
H 0 249.62 15971.60 8094.74
T 0 45.00 2954.42 2954.42
165 12034.63 774601.02 21483.88
Other 0 274.75 9210.23 0.00
-------------------------------------------------
Total 165 12713.00 815573.41 46956.56