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: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 14 7.75 286.75 37.00
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 18 18.00 262.50 14.58
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 37 51.50 1914.75 37.18
TCM-T1017TL-TARGETED CASE MANAGEMENT 208 572.50 21278.50 37.17
TCON-TCON-TRANSITION CONFERENCE 1 1.00 0.00 0.00
Subtotal (Total Children Is Unduplicated) 235 650.75 23742.50 36.48
----------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
AUDE-92552-PURE TONE AUDIOMETRY -AIR ONLY 22 23.00 248.51 10.80
AUDE-92553-PURE TONE AUDIOMETRY AIR & BONE 5 5.00 77.98 15.60
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 683 719.00 6286.96 8.74
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 602 637.00 6871.77 10.79
AUDE-92568-ACOUSTIC REFLEX TESTING (MEMR) 11 11.00 91.19 8.29
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 652 682.04 14303.53 20.97
AUDE-92585-AUD EVOKED RESPONSE (DIAG) 12 19.00 1027.56 54.08
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 62 60.84 1714.42 28.18
AUDE-92588-OTOACOUSTIC EMISSIONS (COMP) 34 37.00 1188.13 32.11
AUDE-V5090-DISPENSING FEE PER HEARING AID 2 4.00 478.40 119.60
BEHV-H0031HO-COMP BEHAVIORAL HEALTH ASSESSMENT 1 1.00 235.80 235.80
EVAL-EVAL-DEVELOPMENTAL EVALUATION 58 100.00 5180.00 51.80
EXIT-EXIT-TRANSITION ASSESSMENT 1 1.00 50.00 50.00
IPDEF-IPDEF_NM-F/U PSYCH & DEV EVAL BY NON-MED PROF 3 5.50 305.25 55.50
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 196 291.45 21806.12 74.82
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 48 68.31 5595.80 81.92
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 106 138.56 10339.48 74.62
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 161 248.00 21490.63 86.66
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 76 117.80 7399.00 62.81
IPDEI-IPDEI_NM-INITIAL PSYCH & DEV EVAL BY NON-MED PR 17 27.06 1637.39 60.51
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 1320 1920.85 142653.26 74.27
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 628 984.95 75260.15 76.41
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 568 782.85 58065.88 74.17
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 522 796.05 45658.35 57.36
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 581 801.25 72851.40 90.92
MED-99201-OUTPATIENT VISIT, NEW, 10 MINS 1 1.00 25.96 25.96
MED-99202-OUTPATIENT VISIT, NEW, 20 MINS 15 15.00 415.09 27.67
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 79 79.00 14615.00 185.00
MED-99204-OUTPATIENT VISIT, NEW, 45 MINS 66 66.00 4590.53 69.55
MED-99205-OUTPATIENT VISIT, NEW, 60 MINS 11 11.00 855.15 77.74
MED-99212-OUTPATIENT VISIT, EST, 10 MINS 1 1.00 18.17 18.17
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 13 13.00 1365.00 105.00
MED-99214-OUTPATIENT VISIT, EST, 25 MINS 6 6.00 341.11 56.85
MED-99215-OUTPATIENT VISIT, EST, 40 MINS 4 7.00 376.13 53.73
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 46 45.96 2207.46 48.03
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 200 208.53 13359.04 64.06
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 46 47.09 2263.70 48.07
PSTH-97001-EVAL BY LICENSED PT, INITIAL 131 133.41 6948.36 52.08
SCREEN-T1023-INTERDISCIPLINARY SCREENING 14 14.00 700.00 50.00
SPCH-92506-SPEECH EVAL BY LICENSED SLP 301 346.81 18345.66 52.90
Subtotal (Total Children Is Unduplicated) 3201 9477.31 567243.32 59.85
----------------------------------------------------------------------------------------------------------------
EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 16 81.75 23628.17 289.03
AUD-HA_FUP-AUDIOLOGY SERVICES 6 6.90 340.84 49.40
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 12 15.50 735.00 47.42
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 7 8.50 425.00 50.00
CONIP-CONIP-CONSULT, ITDS, PHONE 2 0.75 18.75 25.00
CONOF-CONOF-CONSULT, OT, FACE TO FACE 12 19.50 975.00 50.00
CONPF-CONPF-CONSULT, PT, FACE TO FACE 12 12.75 627.50 49.22
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 13 15.25 762.50 50.00
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 2 3.00 75.00 25.00
EIIF-96154-HEALTH AND BEHAVIOR INTERVENTION 2 5.50 275.00 50.00
EIIF-EIIF_NM-EI INDIVIDUAL SESSION BY NONMED PROF 2 8.00 400.00 50.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 180 1029.01 63503.30 61.71
HERN-T1027SC-EI HEARING SERVICES AFTER SHINE 3 4.00 200.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 1337 10205.4 724850.22 71.03
OCCT-97530HM-OT SESSION BY OT ASST 68 230.22 12657.28 54.98
PHY-97110-PT SESSION BY LICENSED PT 1226 9497.29 654782.59 68.94
PHY-97110HM-PT SESSION BY PT ASST 46 198.04 10449.12 52.76
SENS-HA_EIP-ONE UNIT UP TO $500 PER AID 2 3.44 1721.55 500.45
SENS-V5050-MED HEARING AID - ANALOG/DIGITAL 1 2.00 474.24 237.12
SENS-V5264-EARMOLD 8 16.00 299.52 18.72
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 2198 15566.3 1073008.91 68.93
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 22 77.50 4250.48 54.84
SPL-92508-GROUP SPL SESSION PER CHILD 58 173.39 2588.03 14.93
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 48 2790.00 2028.90 0.73
Subtotal (Total Children Is Unduplicated) 3504 39970.0 2579076.90 64.53
----------------------------------------------------------------------------------------------------------------
Total 50098.07 3170062.72 63.28
----------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 5410
----------------------------------------------------------------------------------------------------------------
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 287 457.25 35466.36 36177.36
D 11 16.50 1120.50 0.00
S 94 104.00 3848.00 0.00
H 55 76.75 4789.88 0.00
T 39 56.00 3647.46 3647.46
1198 1679.30 150292.42 0.00
Other 163 252.75 11042.95 0.00
-------------------------------------------------
Total 1847 2642.55 210207.57 39824.82
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 0 457.25 35466.36 36177.36
D 0 16.50 1120.50 0.00
S 0 104.00 3848.00 0.00
H 0 76.75 4789.88 0.00
T 0 56.00 3647.46 3647.46
231 1870.80 158152.92 0.00
Other 0 252.75 11042.95 0.00
-------------------------------------------------
Total 231 2834.05 218068.07 39824.82
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 0 457.25 35466.36 36177.36
D 0 16.50 1120.50 0.00
S 0 104.00 3848.00 0.00
H 0 76.75 4789.88 0.00
T 0 56.00 3647.46 3647.46
0 1870.80 158152.92 0.00
Other 291 543.75 15302.62 0.00
-------------------------------------------------
Total 291 3125.05 222327.74 39824.82
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 135 641.75 54396.76 63768.15
D 16 41.50 3730.56 1153.96
S 0 104.00 3848.00 0.00
H 149 384.98 24128.35 19501.04
T 0 56.00 3647.46 3647.46
11 1881.80 159477.92 0.00
Other 0 543.75 15302.62 0.00
-------------------------------------------------
Total 311 3653.78 264531.67 88070.61
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 0 641.75 54396.76 63768.15
D 0 41.50 3730.56 1153.96
S 0 104.00 3848.00 0.00
H 0 384.98 24128.35 19501.04
T 0 56.00 3647.46 3647.46
6750 5529.51 402958.09 0.00
Other 0 543.75 15302.62 0.00
-------------------------------------------------
Total 6750 7301.49 508011.84 88070.61
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 0 641.75 54396.76 63768.15
D 0 41.50 3730.56 1153.96
S 0 104.00 3848.00 0.00
H 0 384.98 24128.35 19501.04
T 0 56.00 3647.46 3647.46
9526 13999.76 891476.84 0.00
Other 0 543.75 15302.62 0.00
-------------------------------------------------
Total 9526 15771.74 996530.59 88070.61
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 24 1027.75 57275.54 66646.93
D 0 41.50 3730.56 1153.96
S 0 104.00 3848.00 0.00
H 0 384.98 24128.35 19501.04
T 0 56.00 3647.46 3647.46
177 14366.01 922326.03 0.00
Other 0 543.75 15302.62 0.00
-------------------------------------------------
Total 201 16523.99 1030258.56 90949.39
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 364 1549.75 92249.76 107464.59
D 0 41.50 3730.56 1153.96
S 0 104.00 3848.00 0.00
H 0 384.98 24128.35 19501.04
T 0 56.00 3647.46 3647.46
5530 23881.51 1557178.67 3036.00
Other 0 543.75 15302.62 0.00
-------------------------------------------------
Total 5894 26561.49 1700085.42 134803.05
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 1551.25 92351.58 107464.59
D 0 41.50 3730.56 1153.96
S 0 104.00 3848.00 0.00
H 0 384.98 24128.35 19501.04
T 0 56.00 3647.46 3647.46
3785 30393.01 1997986.29 3036.00
Other 0 543.75 15302.62 0.00
-------------------------------------------------
Total 3786 33074.49 2140994.86 134803.05
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 27 1687.00 96644.32 111757.33
D 0 41.50 3730.56 1153.96
S 0 104.00 3848.00 0.00
H 0 384.98 24128.35 19501.04
T 0 56.00 3647.46 3647.46
483 31460.76 2073968.95 3036.00
Other 0 543.75 15302.62 0.00
-------------------------------------------------
Total 510 34277.99 2221270.26 139095.79
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 96 1829.20 107943.83 121030.78
D 1 45.00 3968.14 1153.96
S 0 104.00 3848.00 0.00
H 291 909.98 56179.99 19501.04
T 0 56.00 3647.46 3647.46
1985 35213.88 2308428.37 3156.00
Other 0 543.75 15302.62 0.00
-------------------------------------------------
Total 2373 38701.81 2499318.41 148489.24
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 37 1867.49 111999.11 124111.99
D 0 45.00 3968.14 1153.96
S 0 104.00 3848.00 0.00
H 0 909.98 56179.99 19501.04
T 0 56.00 3647.46 3647.46
1273 36440.52 2383832.30 6795.00
Other 55 631.25 23046.62 205.50
-------------------------------------------------
Total 1365 40054.24 2586521.62 155414.95
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 84 1970.35 134083.29 135987.01
D 0 45.00 3968.14 1153.96
S 1 105.00 4083.80 0.00
H 0 909.98 56179.99 19501.04
T 0 56.00 3647.46 3647.46
2690 42023.79 2670555.16 7024.61
Other 0 631.25 23046.62 205.50
-------------------------------------------------
Total 2775 45741.37 2895564.46 167519.58
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 13 1982.85 134903.31 136671.81
D 4 50.50 4318.14 1153.96
S 0 105.00 4083.80 0.00
H 10 924.98 57547.99 19501.04
T 0 56.00 3647.46 3647.46
3709 44474.74 2831713.36 7024.61
Other 0 631.25 23046.62 205.50
-------------------------------------------------
Total 3736 48225.32 3059260.68 168204.38
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 1982.85 134903.31 136671.81
D 0 50.50 4318.14 1153.96
S 2 257.00 4294.56 210.76
H 0 924.98 57547.99 19501.04
T 3 65.50 4149.28 4149.28
699 46141.99 2939929.01 57769.05
Other 0 631.25 23046.62 205.50
-------------------------------------------------
Total 704 50054.07 3168188.91 219661.40
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 1982.85 134903.31 136671.81
D 0 50.50 4318.14 1153.96
S 0 257.00 4294.56 210.76
H 0 924.98 57547.99 19501.04
T 0 65.50 4149.28 4149.28
22 46185.99 2941802.82 57769.05
Other 0 631.25 23046.62 205.50
-------------------------------------------------
Total 22 50098.07 3170062.72 219661.40