CMS/EIP Fiscal Report Statewide
Services beginning 01/01/2008 ending 12/31/2008 Date of Report:02/17/2009 Page: 1
Payclass Filters:OTHER
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 12 3.75 138.75 37.00
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 32 32.00 0.00 0.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 18 14.00 518.00 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 325 958.50 35445.25 36.98
Subtotal (Total Children Is Unduplicated) 352 1008.25 36102.00 35.81
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Screening, Eval, and Assessment,Class #02
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 6 6.00 51.18 8.53
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 4 4.00 42.36 10.59
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 6 6.00 121.16 20.19
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 2 2.00 55.47 27.74
AUDE-V5010-ASSESSMENT FOR HEARING AID 1 1.00 18.00 18.00
EVAL-EVAL-DEVELOPMENTAL EVALUATION 7 7.50 383.25 51.10
EXIT-EXIT-TRANSITION ASSESSMENT 1 1.00 50.00 50.00
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 4 4.00 300.00 75.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 1.00 75.00 75.00
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 5 5.00 375.00 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 1 1.00 75.00 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 1 0.50 27.75 55.50
IPDEI-IPDEI_NM-INITIAL PSYCH & DEV EVAL BY NON-MED PR 5 5.00 244.00 48.80
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 75 90.00 6167.00 68.52
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 26 38.00 2536.50 66.75
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 20 25.00 1663.00 66.52
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 56 107.00 5938.50 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 18 31.50 2362.50 75.00
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 78 78.00 14430.00 185.00
MED-99204-OUTPATIENT VISIT, NEW, 45 MINS 1 1.00 275.00 275.00
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 8 8.00 840.00 105.00
MED-99214-OUTPATIENT VISIT, EST, 25 MINS 1 1.00 160.00 160.00
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 2 2.00 97.00 48.50
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 13 14.00 679.00 48.50
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 1 1.00 48.50 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 1 1.00 48.50 48.50
SCREEN-T1023-INTERDISCIPLINARY SCREENING 2 2.00 100.00 50.00
SPCH-92506-SPEECH EVAL BY LICENSED SLP 13 13.00 630.50 48.50
Subtotal (Total Children Is Unduplicated) 301 456.50 37794.17 82.79
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 4 10.00 4330.45 433.05
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 14 14.00 737.50 52.68
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 14 9.25 462.50 50.00
CONIP-CONIP-CONSULT, ITDS, PHONE 14 11.00 275.00 25.00
CONOF-CONOF-CONSULT, OT, FACE TO FACE 14 12.00 600.00 50.00
CONOP-CONOP-CONSULT, OT, PHONE 9 11.00 300.00 27.27
CONPF-CONPF-CONSULT, PT, FACE TO FACE 6 7.00 350.00 50.00
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 44 66.50 3325.00 50.00
CONSP-CONSP-CONSULT, SLP, PHONE 24 11.50 287.77 25.02
ECE-ECE-EARLY CHILDHOOD EDUCATION 13 2324.00 20916.00 9.00
EIGF-EIGF_NM-EI GROUP SESSION BY NONMED PROF 73 3554.00 88850.00 25.00
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 50 1265.00 31625.00 25.00
EIIF-EIIF_NM-EI INDIVIDUAL SESSION BY NONMED PROF 26 269.00 13450.00 50.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 73 415.50 20715.00 49.86
OCCT-97530-OT SESSION BY LICENSED OT 51 253.00 17122.79 67.68
OCCT-97530HM-OT SESSION BY OT ASST 1 1.50 81.48 54.32
PHY-97110-PT SESSION BY LICENSED PT 89 479.50 32521.34 67.82
PHY-97110HM-PT SESSION BY PT ASST 7 33.00 1799.34 54.53
SHIN-T1027SC-INITIAL SHINE SERVICES, INDIVIDUAL 2 2.50 125.00 50.00
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 159 632.52 42817.26 67.69
SPL-92508-GROUP SPL SESSION PER CHILD 12 126.50 1669.80 13.20
TRAN-TRAN-FAMILY TRANSPORTATION 50 4444.00 436241.00 98.16
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 288 35225.4 19284.14 0.55
VISN-EIIF_NM-EI VISION SERVICES, IND NONMED 10 138.00 6900.00 50.00
Subtotal (Total Children Is Unduplicated) 751 49315.7 744786.37 15.10
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Total 50780.40 818682.54 16.12
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Number of Children (Unduplicated) With at Least One Service 1339
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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 26 2434.00 1217.00 1217.00
D 0 0.00 0.00 0.00
S 0 0.00 0.00 0.00
H 0 0.00 0.00 0.00
T 14 58.00 2175.00 2175.00
382 6582.50 54653.78 2162.97
Other 2 4.00 200.00 0.00
-------------------------------------------------
Total 424 9078.50 58245.78 5554.97
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 2434.00 1217.00 1217.00
D 0 0.00 0.00 0.00
S 0 0.00 0.00 0.00
H 0 0.00 0.00 0.00
T 0 58.00 2175.00 2175.00
2 6585.00 54784.28 2162.97
Other 0 4.00 200.00 0.00
-------------------------------------------------
Total 2 9081.00 58376.28 5554.97
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 2434.00 1217.00 1217.00
D 0 0.00 0.00 0.00
S 0 0.00 0.00 0.00
H 0 0.00 0.00 0.00
T 0 58.00 2175.00 2175.00
0 6585.00 54784.28 2162.97
Other 14 18.00 407.67 0.00
-------------------------------------------------
Total 14 9095.00 58583.95 5554.97
Center 04
Flag Claims Units Chgs Paid
-------------------------------------------------
R 0 0.00 0.00 0.00
U 0 0.00 0.00 0.00
B 3 3.00 225.00 0.00
P 0 2434.00 1217.00 1217.00
D 0 0.00 0.00 0.00
S 0 0.00 0.00 0.00
H 0 0.00 0.00 0.00
T 0 58.00 2175.00 2175.00
505 11451.00 190564.28 2162.97
Other 0 18.00 407.67 0.00
-------------------------------------------------
Total 508 13964.00 194588.95 5554.97
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 3.00 225.00 0.00
P 0 2434.00 1217.00 1217.00
D 0 0.00 0.00 0.00
S 0 0.00 0.00 0.00
H 0 0.00 0.00 0.00
T 0 58.00 2175.00 2175.00
796 27222.25 218856.16 2162.97
Other 0 18.00 407.67 0.00
-------------------------------------------------
Total 796 29735.25 222880.83 5554.97
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 3.00 225.00 0.00
P 0 2434.00 1217.00 1217.00
D 0 0.00 0.00 0.00
S 0 0.00 0.00 0.00
H 0 0.00 0.00 0.00
T 0 58.00 2175.00 2175.00
289 27531.50 225906.27 2162.97
Other 0 18.00 407.67 0.00
-------------------------------------------------
Total 289 30044.50 229930.94 5554.97
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 3.00 225.00 0.00
P 0 2434.00 1217.00 1217.00
D 0 0.00 0.00 0.00
S 8 12.25 716.25 0.00
H 0 0.00 0.00 0.00
T 0 58.00 2175.00 2175.00
101 27897.75 234411.94 2162.97
Other 0 18.00 407.67 0.00
-------------------------------------------------
Total 109 30423.00 239152.86 5554.97
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 3.00 225.00 0.00
P 137 2941.75 32547.71 32547.71
D 0 0.00 0.00 0.00
S 0 12.25 716.25 0.00
H 0 0.00 0.00 0.00
T 0 58.00 2175.00 2175.00
1002 28822.50 274312.33 2162.97
Other 0 18.00 407.67 0.00
-------------------------------------------------
Total 1139 31855.50 310383.96 36885.68
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 3.00 225.00 0.00
P 0 2941.75 32547.71 32547.71
D 0 0.00 0.00 0.00
S 0 12.25 716.25 0.00
H 0 0.00 0.00 0.00
T 0 58.00 2175.00 2175.00
1 28822.75 274321.58 2162.97
Other 0 18.00 407.67 0.00
-------------------------------------------------
Total 1 31855.75 310393.21 36885.68
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 3.00 225.00 0.00
P 5 3146.75 32965.09 32965.09
D 0 0.00 0.00 0.00
S 0 12.25 716.25 0.00
H 0 0.00 0.00 0.00
T 0 58.00 2175.00 2175.00
77 29180.00 287335.55 2162.97
Other 0 18.00 407.67 0.00
-------------------------------------------------
Total 82 32418.00 323824.56 37303.06
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 3.00 225.00 0.00
P 0 3146.75 32965.09 32965.09
D 0 0.00 0.00 0.00
S 0 12.25 716.25 0.00
H 0 0.00 0.00 0.00
T 0 58.00 2175.00 2175.00
444 36934.90 305723.91 2162.97
Other 0 18.00 407.67 0.00
-------------------------------------------------
Total 444 40172.90 342212.92 37303.06
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 3.00 225.00 0.00
P 0 3146.75 32965.09 32965.09
D 0 0.00 0.00 0.00
S 0 12.25 716.25 0.00
H 0 0.00 0.00 0.00
T 0 58.00 2175.00 2175.00
4 37081.90 305825.41 2162.97
Other 0 18.00 407.67 0.00
-------------------------------------------------
Total 4 40319.90 342314.42 37303.06
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 3.00 225.00 0.00
P 0 3146.75 32965.09 32965.09
D 0 0.00 0.00 0.00
S 0 12.25 716.25 0.00
H 0 0.00 0.00 0.00
T 0 58.00 2175.00 2175.00
99 37179.15 309423.66 2162.97
Other 0 18.00 407.67 0.00
-------------------------------------------------
Total 99 40417.15 345912.67 37303.06
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 3.00 225.00 0.00
P 0 3146.75 32965.09 32965.09
D 0 0.00 0.00 0.00
S 1 15.75 762.45 237.58
H 0 0.00 0.00 0.00
T 1 118.00 2205.00 2205.00
288 46555.65 771115.16 2162.97
Other 128 938.25 11184.84 10802.17
-------------------------------------------------
Total 418 50777.40 818457.54 48372.81
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 3.00 225.00 0.00
P 0 3146.75 32965.09 32965.09
D 0 0.00 0.00 0.00
S 0 15.75 762.45 237.58
H 0 0.00 0.00 0.00
T 0 118.00 2205.00 2205.00
3 46558.65 771340.16 2162.97
Other 0 938.25 11184.84 10802.17
-------------------------------------------------
Total 3 50780.40 818682.54 48372.81