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:Program Patients
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 11 5.50 203.50 37.00
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 4 4.00 262.50 65.63
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 24 25.00 925.00 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 151 317.50 11692.00 36.83
Subtotal (Total Children Is Unduplicated) 154 352.00 13083.00 37.17
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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) 170 170.00 1501.10 8.83
AUDE-92557-COMP AUDIO THRESHOLD EVAL/SPCH RECOG 1 1.00 27.10 27.10
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 149 150.00 1619.58 10.80
AUDE-92568-ACOUSTIC REFLEX TESTING (MEMR) 3 3.00 25.32 8.44
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 168 168.00 3660.72 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 18 27.00 1350.00 50.00
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 72 103.50 7762.50 75.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 13 16.00 1387.50 86.72
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 22 24.50 1837.50 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 48 78.00 6187.50 79.33
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 18 27.00 1498.50 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 504 731.37 54498.04 74.52
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 155 242.50 18622.00 76.79
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 220 303.11 22399.50 73.90
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 224 343.50 19064.25 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 179 242.50 18825.00 77.63
MED-99202-OUTPATIENT VISIT, NEW, 20 MINS 6 6.00 163.32 27.22
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 9 9.00 1665.00 185.00
MED-99204-OUTPATIENT VISIT, NEW, 45 MINS 21 21.00 1420.40 67.64
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
MED-99215-OUTPATIENT VISIT, EST, 40 MINS 2 2.00 100.30 50.15
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 9 9.00 450.00 50.00
SPCH-92506-SPEECH EVAL BY LICENSED SLP 76 77.00 4090.87 53.13
Subtotal (Total Children Is Unduplicated) 1027 2878.53 174230.49 60.53
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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 610 2653.86 185504.52 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 1051 4086.91 278382.89 68.12
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 11 319.00 159.50 0.50
Subtotal (Total Children Is Unduplicated) 1754 10086.0 663958.39 65.83
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Total 13316.50 851271.88 63.93
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Number of Children (Unduplicated) With at Least One Service 2611
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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 7 7.50 277.50 0.00
H 31 37.50 2481.50 0.00
T 49 68.00 4513.67 4513.67
490 505.50 25255.77 0.00
Other 124 232.25 9602.85 0.00
-------------------------------------------------
Total 705 863.00 44219.02 6443.15
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 7.50 277.50 0.00
H 0 37.50 2481.50 0.00
T 0 68.00 4513.67 4513.67
78 578.00 28337.77 0.00
Other 0 232.25 9602.85 0.00
-------------------------------------------------
Total 78 935.50 47301.02 6443.15
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 7.50 277.50 0.00
H 0 37.50 2481.50 0.00
T 0 68.00 4513.67 4513.67
0 578.00 28337.77 0.00
Other 83 315.25 10857.19 0.00
-------------------------------------------------
Total 83 1018.50 48555.36 6443.15
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 19 31.75 4631.98 6108.65
D 8 17.00 1120.06 1153.96
S 0 7.50 277.50 0.00
H 53 164.37 10567.02 8094.74
T 0 68.00 4513.67 4513.67
2 580.00 28487.77 0.00
Other 0 315.25 10857.19 0.00
-------------------------------------------------
Total 82 1183.87 60455.19 19871.02
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 31.75 4631.98 6108.65
D 0 17.00 1120.06 1153.96
S 0 7.50 277.50 0.00
H 0 164.37 10567.02 8094.74
T 0 68.00 4513.67 4513.67
2009 1679.50 102252.30 0.00
Other 0 315.25 10857.19 0.00
-------------------------------------------------
Total 2009 2283.37 134219.72 19871.02
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 31.75 4631.98 6108.65
D 0 17.00 1120.06 1153.96
S 0 7.50 277.50 0.00
H 0 164.37 10567.02 8094.74
T 0 68.00 4513.67 4513.67
2392 3701.50 220200.77 0.00
Other 0 315.25 10857.19 0.00
-------------------------------------------------
Total 2392 4305.37 252168.19 19871.02
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 31.75 4631.98 6108.65
D 0 17.00 1120.06 1153.96
S 0 7.50 277.50 0.00
H 0 164.37 10567.02 8094.74
T 0 68.00 4513.67 4513.67
27 3769.75 224738.18 0.00
Other 0 315.25 10857.19 0.00
-------------------------------------------------
Total 27 4373.62 256705.60 19871.02
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 69.25 7158.10 11415.36
D 0 17.00 1120.06 1153.96
S 0 7.50 277.50 0.00
H 0 164.37 10567.02 8094.74
T 0 68.00 4513.67 4513.67
1778 6619.50 420242.92 1938.00
Other 0 315.25 10857.19 0.00
-------------------------------------------------
Total 1805 7260.87 454736.46 27115.73
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 70.75 7259.92 11415.36
D 0 17.00 1120.06 1153.96
S 0 7.50 277.50 0.00
H 0 164.37 10567.02 8094.74
T 0 68.00 4513.67 4513.67
1112 8465.75 545560.77 1938.00
Other 0 315.25 10857.19 0.00
-------------------------------------------------
Total 1113 9108.62 580156.13 27115.73
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 70.75 7259.92 11415.36
D 0 17.00 1120.06 1153.96
S 0 7.50 277.50 0.00
H 0 164.37 10567.02 8094.74
T 0 68.00 4513.67 4513.67
144 8811.25 565670.57 1938.00
Other 0 315.25 10857.19 0.00
-------------------------------------------------
Total 144 9454.12 600265.93 27115.73
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 72.75 7395.68 11415.36
D 0 17.00 1120.06 1153.96
S 0 7.50 277.50 0.00
H 79 288.62 18529.10 8094.74
T 0 68.00 4513.67 4513.67
677 10117.57 646084.89 1938.00
Other 0 315.25 10857.19 0.00
-------------------------------------------------
Total 757 10886.69 688778.09 27115.73
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 72.75 7395.68 11415.36
D 0 17.00 1120.06 1153.96
S 0 7.50 277.50 0.00
H 0 288.62 18529.10 8094.74
T 0 68.00 4513.67 4513.67
267 10375.86 660037.90 1938.00
Other 0 315.25 10857.19 0.00
-------------------------------------------------
Total 267 11144.98 702731.10 27115.73
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 89.00 11702.28 13924.18
D 0 17.00 1120.06 1153.96
S 1 8.50 513.30 0.00
H 0 288.62 18529.10 8094.74
T 0 68.00 4513.67 4513.67
587 11384.84 727392.11 1938.00
Other 0 315.25 10857.19 0.00
-------------------------------------------------
Total 604 12171.21 774627.71 29624.55
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 89.00 11702.28 13924.18
D 0 17.00 1120.06 1153.96
S 0 8.50 513.30 0.00
H 0 288.62 18529.10 8094.74
T 0 68.00 4513.67 4513.67
1076 12118.63 776758.68 1938.00
Other 0 315.25 10857.19 0.00
-------------------------------------------------
Total 1076 12905.00 823994.28 29624.55
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 89.00 11702.28 13924.18
D 0 17.00 1120.06 1153.96
S 0 8.50 513.30 0.00
H 0 288.62 18529.10 8094.74
T 0 68.00 4513.67 4513.67
165 12530.13 804036.28 21483.88
Other 0 315.25 10857.19 0.00
-------------------------------------------------
Total 165 13316.50 851271.88 49170.43