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: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
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 2 2.00 0.00 0.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 7 6.25 231.25 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 33 90.25 3256.00 36.08
Subtotal (Total Children Is Unduplicated) 37 99.00 3505.75 35.41
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Screening, Eval, and Assessment,Class #02
AUDE-92552-PURE TONE AUDIOMETRY -AIR ONLY 2 2.00 21.24 10.62
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 102 102.00 877.26 8.60
AUDE-92557-COMP AUDIO THRESHOLD EVAL/SPCH RECOG 1 1.00 27.10 27.10
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 88 88.00 941.16 10.70
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 101 101.00 2081.04 20.60
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 6 6.00 168.59 28.10
EVAL-EVAL-DEVELOPMENTAL EVALUATION 2 3.00 150.00 50.00
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 36 41.50 3112.50 75.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 7 10.68 988.44 92.55
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 21 24.50 1811.00 73.92
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 20 22.50 2850.00 126.67
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 17 24.50 1359.75 55.50
IPDEI-IPDEI_NM-INITIAL PSYCH & DEV EVAL BY NON-MED PR 8 9.76 944.31 96.75
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 416 576.15 42608.38 73.95
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 148 205.80 15773.22 76.64
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 181 228.00 16960.00 74.39
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 268 407.76 22701.06 55.67
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 242 297.66 30546.89 102.62
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 21 21.00 3885.00 185.00
MED-99204-OUTPATIENT VISIT, NEW, 45 MINS 4 4.00 243.40 60.85
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 1 1.00 105.00 105.00
PSTH-97001-EVAL BY LICENSED PT, INITIAL 3 3.00 145.50 48.50
SCREEN-T1023-INTERDISCIPLINARY SCREENING 9 9.00 450.00 50.00
SPCH-92506-SPEECH EVAL BY LICENSED SLP 4 5.30 237.00 44.72
Subtotal (Total Children Is Unduplicated) 818 2195.11 148987.84 67.87
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 2 2.00 100.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 2 14.00 900.76 64.34
PHY-97110-PT SESSION BY LICENSED PT 3 3.50 237.58 67.88
PHY-97110HM-PT SESSION BY PT ASST 1 1.00 54.32 54.32
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 5 7.50 636.33 84.84
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 5 260.00 130.00 0.50
Subtotal (Total Children Is Unduplicated) 16 288.00 2058.99 7.15
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Total 2582.11 154552.58 59.86
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Number of Children (Unduplicated) With at Least One Service 853
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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 8 8.75 646.75 609.56
D 6 11.00 717.75 0.00
S 4 8.50 314.50 0.00
H 15 18.75 1234.00 0.00
T 17 23.00 1559.25 1559.25
38 58.25 2776.59 0.00
Other 10 14.00 933.00 0.00
-------------------------------------------------
Total 98 142.25 8181.84 2168.81
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 8.75 646.75 609.56
D 0 11.00 717.75 0.00
S 0 8.50 314.50 0.00
H 0 18.75 1234.00 0.00
T 0 23.00 1559.25 1559.25
34 93.00 4260.09 0.00
Other 0 14.00 933.00 0.00
-------------------------------------------------
Total 34 177.00 9665.34 2168.81
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 8.75 646.75 609.56
D 0 11.00 717.75 0.00
S 0 8.50 314.50 0.00
H 0 18.75 1234.00 0.00
T 0 23.00 1559.25 1559.25
0 93.00 4260.09 0.00
Other 52 66.00 1676.25 0.00
-------------------------------------------------
Total 52 229.00 10408.59 2168.81
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 35 46.25 5203.25 8008.45
D 3 14.00 1272.75 0.00
S 0 8.50 314.50 0.00
H 0 18.75 1234.00 0.00
T 0 23.00 1559.25 1559.25
1 94.00 4445.09 0.00
Other 0 66.00 1676.25 0.00
-------------------------------------------------
Total 39 270.50 15705.09 9567.70
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 46.25 5203.25 8008.45
D 0 14.00 1272.75 0.00
S 0 8.50 314.50 0.00
H 0 18.75 1234.00 0.00
T 0 23.00 1559.25 1559.25
22 117.00 6136.35 0.00
Other 0 66.00 1676.25 0.00
-------------------------------------------------
Total 22 293.50 17396.35 9567.70
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 46.25 5203.25 8008.45
D 0 14.00 1272.75 0.00
S 0 8.50 314.50 0.00
H 0 18.75 1234.00 0.00
T 0 23.00 1559.25 1559.25
405 575.50 25365.96 0.00
Other 0 66.00 1676.25 0.00
-------------------------------------------------
Total 405 752.00 36625.96 9567.70
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 2 48.25 5353.25 8158.45
D 0 14.00 1272.75 0.00
S 0 8.50 314.50 0.00
H 0 18.75 1234.00 0.00
T 0 23.00 1559.25 1559.25
376 975.50 54044.06 0.00
Other 0 66.00 1676.25 0.00
-------------------------------------------------
Total 378 1154.00 65454.06 9717.70
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 48.25 5353.25 8158.45
D 0 14.00 1272.75 0.00
S 0 8.50 314.50 0.00
H 0 18.75 1234.00 0.00
T 0 23.00 1559.25 1559.25
501 1779.00 108729.81 0.00
Other 0 66.00 1676.25 0.00
-------------------------------------------------
Total 501 1957.50 120139.81 9717.70
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 48.25 5353.25 8158.45
D 0 14.00 1272.75 0.00
S 0 8.50 314.50 0.00
H 0 18.75 1234.00 0.00
T 0 23.00 1559.25 1559.25
1 1780.00 108785.31 0.00
Other 0 66.00 1676.25 0.00
-------------------------------------------------
Total 1 1958.50 120195.31 9717.70
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 7 56.75 5901.00 8616.95
D 0 14.00 1272.75 0.00
S 0 8.50 314.50 0.00
H 48 83.25 5400.50 0.00
T 0 23.00 1559.25 1559.25
49 2090.05 111797.31 120.00
Other 0 66.00 1676.25 0.00
-------------------------------------------------
Total 104 2341.55 127921.56 10296.20
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 3 60.77 6540.62 8947.71
D 0 14.00 1272.75 0.00
S 0 8.50 314.50 0.00
H 0 83.25 5400.50 0.00
T 0 23.00 1559.25 1559.25
4 2098.05 112358.31 420.00
Other 2 69.00 1872.00 0.00
-------------------------------------------------
Total 9 2356.57 129317.93 10926.96
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 22 87.77 12446.88 12043.68
D 1 15.00 1535.25 144.38
S 1 10.00 577.00 2.65
H 0 83.25 5400.50 0.00
T 0 23.00 1559.25 1559.25
117 2221.42 126000.70 483.29
Other 0 69.00 1872.00 0.00
-------------------------------------------------
Total 141 2509.44 149391.58 14233.25
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 87.77 12446.88 12043.68
D 0 15.00 1535.25 144.38
S 0 10.00 577.00 2.65
H 0 83.25 5400.50 0.00
T 0 23.00 1559.25 1559.25
43 2293.09 131106.20 483.29
Other 0 69.00 1872.00 0.00
-------------------------------------------------
Total 43 2581.11 154497.08 14233.25
Center 58
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 87.77 12446.88 12043.68
D 0 15.00 1535.25 144.38
S 0 10.00 577.00 2.65
H 0 83.25 5400.50 0.00
T 0 23.00 1559.25 1559.25
1 2294.09 131161.70 483.29
Other 0 69.00 1872.00 0.00
-------------------------------------------------
Total 1 2582.11 154552.58 14233.25