CMS/EIP Fiscal Report Statewide
Services beginning 07/01/2008 ending 09/30/2008 Date of Report:11/18/2008 Page: 1
Agency Filter:EIP DEI DEIP
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
----------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 131 131.00 1156.73 8.83
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 108 108.00 1166.40 10.80
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 125 125.00 2723.75 21.79
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 13 13.00 367.64 28.28
EVAL-EVAL-DEVELOPMENTAL EVALUATION 11 15.50 775.00 50.00
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 48 73.00 5475.00 75.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 7 8.00 600.00 75.00
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 15 16.50 1237.50 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-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 295 447.00 33525.00 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 107 176.50 13725.00 77.76
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 135 200.00 15000.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 135 211.50 11738.25 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 128 177.50 13950.00 78.59
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 1 1.00 48.50 48.50
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 5 5.00 457.40 91.48
SCREEN-T1023-INTERDISCIPLINARY SCREENING 3 3.00 150.00 50.00
SPCH-92506-SPEECH EVAL BY LICENSED SLP 8 8.00 388.00 48.50
Subtotal (Total Children Is Unduplicated) 587 1855.50 112898.85 60.85
----------------------------------------------------------------------------------------------------------------
EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 2 2.50 125.00 50.00
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 1 1.00 50.00 50.00
CONOF-CONOF-CONSULT, OT, FACE TO FACE 2 2.00 100.00 50.00
CONPF-CONPF-CONSULT, PT, FACE TO FACE 2 2.00 100.00 50.00
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 6 6.00 300.00 50.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 44 189.25 14824.90 78.34
OCCT-97530-OT SESSION BY LICENSED OT 50 276.25 20068.46 72.65
PHY-97110-PT SESSION BY LICENSED PT 15 86.00 5837.68 67.88
PHY-97110HM-PT SESSION BY PT ASST 1 1.00 54.32 54.32
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 46 176.25 11963.85 67.88
SPL-92508-GROUP SPL SESSION PER CHILD 1 1.00 13.20 13.20
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 4 82.00 41.00 0.50
Subtotal (Total Children Is Unduplicated) 151 825.25 53478.41 64.80
----------------------------------------------------------------------------------------------------------------
Total 2994.75 178054.26 59.46
----------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 847
----------------------------------------------------------------------------------------------------------------
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 2 2.50 158.25 0.00
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 31 44.00 2891.00 2891.00
278 177.75 6674.50 0.00
Other 0 0.00 0.00 0.00
-------------------------------------------------
Total 336 254.25 11539.50 2891.00
Center 02
Flag Claims Units Chgs Paid
-------------------------------------------------
R 0 0.00 0.00 0.00
U 0 0.00 0.00 0.00
B 0 0.00 0.00 0.00
P 0 2.50 158.25 0.00
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 44.00 2891.00 2891.00
67 234.75 8841.00 0.00
Other 0 0.00 0.00 0.00
-------------------------------------------------
Total 67 311.25 13706.00 2891.00
Center 03
Flag Claims Units Chgs Paid
-------------------------------------------------
R 0 0.00 0.00 0.00
U 0 0.00 0.00 0.00
B 0 0.00 0.00 0.00
P 0 2.50 158.25 0.00
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 44.00 2891.00 2891.00
0 234.75 8841.00 0.00
Other 63 63.00 949.88 0.00
-------------------------------------------------
Total 63 374.25 14655.88 2891.00
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 20.00 2332.50 3524.55
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 44.00 2891.00 2891.00
2 236.75 8991.00 0.00
Other 0 63.00 949.88 0.00
-------------------------------------------------
Total 19 393.75 16980.13 6415.55
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 20.00 2332.50 3524.55
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 44.00 2891.00 2891.00
6 242.75 9386.56 0.00
Other 0 63.00 949.88 0.00
-------------------------------------------------
Total 6 399.75 17375.69 6415.55
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 20.00 2332.50 3524.55
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 44.00 2891.00 2891.00
567 931.25 41087.32 0.00
Other 0 63.00 949.88 0.00
-------------------------------------------------
Total 567 1088.25 49076.45 6415.55
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 1 21.00 2400.38 3592.43
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 44.00 2891.00 2891.00
635 1754.75 98372.65 0.00
Other 0 63.00 949.88 0.00
-------------------------------------------------
Total 636 1912.75 106429.66 6483.43
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 21.00 2400.38 3592.43
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 44.00 2891.00 2891.00
241 2164.75 127360.53 0.00
Other 0 63.00 949.88 0.00
-------------------------------------------------
Total 241 2322.75 135417.54 6483.43
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 21.00 2400.38 3592.43
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 44.00 2891.00 2891.00
13 2212.75 128051.65 0.00
Other 0 63.00 949.88 0.00
-------------------------------------------------
Total 13 2370.75 136108.66 6483.43
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 21.00 2400.38 3592.43
D 0 0.00 0.00 0.00
S 0 4.00 148.00 0.00
H 60 122.75 7886.08 0.00
T 0 44.00 2891.00 2891.00
153 2491.75 143496.48 0.00
Other 0 63.00 949.88 0.00
-------------------------------------------------
Total 213 2746.50 157771.82 6483.43
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 21.00 2400.38 3592.43
D 0 0.00 0.00 0.00
S 0 4.00 148.00 0.00
H 0 122.75 7886.08 0.00
T 0 44.00 2891.00 2891.00
13 2532.50 144328.25 0.00
Other 0 63.00 949.88 0.00
-------------------------------------------------
Total 13 2787.25 158603.59 6483.43
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 15 36.25 6444.48 5940.62
D 0 0.00 0.00 0.00
S 1 5.00 383.80 0.00
H 0 122.75 7886.08 0.00
T 0 44.00 2891.00 2891.00
179 2698.25 157774.02 0.00
Other 0 63.00 949.88 0.00
-------------------------------------------------
Total 195 2969.25 176329.26 8831.62
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 36.25 6444.48 5940.62
D 0 0.00 0.00 0.00
S 0 5.00 383.80 0.00
H 0 122.75 7886.08 0.00
T 0 44.00 2891.00 2891.00
17 2723.75 159499.02 0.00
Other 0 63.00 949.88 0.00
-------------------------------------------------
Total 17 2994.75 178054.26 8831.62