CMS/EIP Fiscal Report Statewide
Services beginning 01/01/2008 ending 12/31/2008 Date of Report:02/17/2009 Page: 1
Payclass Filters:TPIN
Eligibility Filter:DEI Only
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 2 4.25 157.25 37.00
Subtotal (Total Children Is Unduplicated) 2 4.25 157.25 37.00
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Screening, Eval, and Assessment,Class #02
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 1 1.00 8.83 8.83
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 1 1.00 28.28 28.28
EVAL-EVAL-DEVELOPMENTAL EVALUATION 10 13.00 650.00 50.00
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 3 4.50 337.50 75.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 3 4.00 300.00 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 3 5.50 562.50 102.27
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 3 4.00 222.00 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 3 4.00 300.00 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 2 2.00 150.00 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 2 3.50 262.50 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 8 11.00 610.50 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 12 12.00 900.00 75.00
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 4 4.00 740.00 185.00
MED-99205-OUTPATIENT VISIT, NEW, 60 MINS 4 4.00 309.31 77.33
MED-99215-OUTPATIENT VISIT, EST, 40 MINS 7 9.00 488.97 54.33
PSTH-97001-EVAL BY LICENSED PT, INITIAL 4 4.00 194.00 48.50
SCREEN-T1023-INTERDISCIPLINARY SCREENING 1 1.00 50.00 50.00
SPCH-92506-SPEECH EVAL BY LICENSED SLP 4 4.00 194.00 48.50
Subtotal (Total Children Is Unduplicated) 33 91.50 6308.39 68.94
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EI Services,Class #03
OCCT-97530-OT SESSION BY LICENSED OT 1 12.50 848.50 67.88
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 1 1.00 67.88 67.88
Subtotal (Total Children Is Unduplicated) 2 13.50 916.38 67.88
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Total 109.25 7382.02 67.57
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Number of Children (Unduplicated) With at Least One Service 37
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Center 01
Flag Claims Units Chgs Paid
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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 1 2.00 74.00 0.00
H 1 1.00 75.00 0.00
T 0 0.00 0.00 0.00
4 2.25 83.25 0.00
Other 0 0.00 0.00 0.00
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Total 6 5.25 232.25 0.00
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 8 9.00 1066.25 1680.73
D 0 0.00 0.00 0.00
S 0 2.00 74.00 0.00
H 0 1.00 75.00 0.00
T 0 0.00 0.00 0.00
0 2.25 83.25 0.00
Other 0 0.00 0.00 0.00
-------------------------------------------------
Total 8 14.25 1298.50 1680.73
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 9.00 1066.25 1680.73
D 0 0.00 0.00 0.00
S 0 2.00 74.00 0.00
H 0 1.00 75.00 0.00
T 0 0.00 0.00 0.00
35 37.25 1969.53 0.00
Other 0 0.00 0.00 0.00
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Total 35 49.25 3184.78 1680.73
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 9.00 1066.25 1680.73
D 0 0.00 0.00 0.00
S 0 2.00 74.00 0.00
H 0 1.00 75.00 0.00
T 0 0.00 0.00 0.00
5 41.75 2187.02 0.00
Other 0 0.00 0.00 0.00
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Total 5 53.75 3402.27 1680.73
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 0 9.00 1066.25 1680.73
D 0 0.00 0.00 0.00
S 0 2.00 74.00 0.00
H 0 1.00 75.00 0.00
T 0 0.00 0.00 0.00
32 83.25 5055.77 0.00
Other 0 0.00 0.00 0.00
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Total 32 95.25 6271.02 1680.73
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 0 9.00 1066.25 1680.73
D 0 0.00 0.00 0.00
S 0 2.00 74.00 0.00
H 0 1.00 75.00 0.00
T 0 0.00 0.00 0.00
4 97.25 6166.77 0.00
Other 0 0.00 0.00 0.00
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Total 4 109.25 7382.02 1680.73