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: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 16 8.25 305.25 37.00
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 20 20.00 262.50 13.13
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 44 57.75 2146.00 37.16
TCM-T1017TL-TARGETED CASE MANAGEMENT 243 667.00 24691.75 37.02
TCON-TCON-TRANSITION CONFERENCE 1 1.00 0.00 0.00
Subtotal (Total Children Is Unduplicated) 274 754.00 27405.50 36.35
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Screening, Eval, and Assessment,Class #02
AUDE-92552-PURE TONE AUDIOMETRY -AIR ONLY 24 25.00 269.75 10.79
AUDE-92553-PURE TONE AUDIOMETRY AIR & BONE 5 5.00 77.98 15.60
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 786 822.00 7173.05 8.73
AUDE-92557-COMP AUDIO THRESHOLD EVAL/SPCH RECOG 1 1.00 27.10 27.10
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 690 725.00 7812.93 10.78
AUDE-92568-ACOUSTIC REFLEX TESTING (MEMR) 11 11.00 91.19 8.29
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 753 783.04 16384.57 20.92
AUDE-92585-AUD EVOKED RESPONSE (DIAG) 12 19.00 1027.56 54.08
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 69 67.84 1911.29 28.17
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 70 116.00 5980.00 51.55
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 235 337.45 25256.12 74.84
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 58 82.99 6884.24 82.95
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 127 163.06 12150.48 74.52
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 184 276.00 24903.13 90.23
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 96 146.30 8980.75 61.39
IPDEI-IPDEI_NM-INITIAL PSYCH & DEV EVAL BY NON-MED PR 25 36.82 2581.70 70.12
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 1739 2501.00 185561.64 74.19
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 778 1192.75 91183.37 76.45
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 751 1014.35 75288.38 74.22
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 798 1214.81 68969.91 56.77
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 835 1110.91 104298.29 93.89
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 104 104.00 19240.00 185.00
MED-99204-OUTPATIENT VISIT, NEW, 45 MINS 70 70.00 4833.93 69.06
MED-99205-OUTPATIENT VISIT, NEW, 60 MINS 15 15.00 1164.46 77.63
MED-99212-OUTPATIENT VISIT, EST, 10 MINS 1 1.00 18.17 18.17
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 14 14.00 1470.00 105.00
MED-99214-OUTPATIENT VISIT, EST, 25 MINS 6 6.00 341.11 56.85
MED-99215-OUTPATIENT VISIT, EST, 40 MINS 11 16.00 865.10 54.07
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 138 140.41 7287.86 51.90
SCREEN-T1023-INTERDISCIPLINARY SCREENING 24 24.00 1200.00 50.00
SPCH-92506-SPEECH EVAL BY LICENSED SLP 309 356.11 18776.66 52.73
Subtotal (Total Children Is Unduplicated) 4052 11763.9 722539.55 61.42
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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 182 1031.01 63603.30 61.69
HERN-T1027SC-EI HEARING SERVICES AFTER SHINE 3 4.00 200.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 1340 10231.9 726599.48 71.01
OCCT-97530HM-OT SESSION BY OT ASST 68 230.22 12657.28 54.98
PHY-97110-PT SESSION BY LICENSED PT 1229 9500.79 655020.17 68.94
PHY-97110HM-PT SESSION BY PT ASST 47 199.04 10503.44 52.77
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 2204 15574.8 1073713.12 68.94
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 53 3050.00 2158.90 0.71
Subtotal (Total Children Is Unduplicated) 3522 40271.5 2582052.27 64.12
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Total 52789.43 3331997.32 63.12
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Number of Children (Unduplicated) With at Least One Service 6300
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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 295 466.00 36113.11 36786.92
D 17 27.50 1838.25 0.00
S 99 114.50 4236.50 0.00
H 71 96.50 6098.88 0.00
T 56 79.00 5206.71 5206.71
1240 1739.80 153152.26 0.00
Other 173 266.75 11975.95 0.00
-------------------------------------------------
Total 1951 2790.05 218621.66 41993.63
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 0 466.00 36113.11 36786.92
D 0 27.50 1838.25 0.00
S 0 114.50 4236.50 0.00
H 0 96.50 6098.88 0.00
T 0 79.00 5206.71 5206.71
265 1966.05 162496.26 0.00
Other 0 266.75 11975.95 0.00
-------------------------------------------------
Total 265 3016.30 227965.66 41993.63
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 0 466.00 36113.11 36786.92
D 0 27.50 1838.25 0.00
S 0 114.50 4236.50 0.00
H 0 96.50 6098.88 0.00
T 0 79.00 5206.71 5206.71
0 1966.05 162496.26 0.00
Other 343 609.75 16978.87 0.00
-------------------------------------------------
Total 343 3359.30 232968.58 41993.63
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 178 697.00 60666.26 73457.33
D 19 55.50 5003.31 1153.96
S 0 114.50 4236.50 0.00
H 149 404.73 25437.35 19501.04
T 0 79.00 5206.71 5206.71
12 1978.05 164006.26 0.00
Other 0 609.75 16978.87 0.00
-------------------------------------------------
Total 358 3938.53 281535.26 99319.04
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 0 697.00 60666.26 73457.33
D 0 55.50 5003.31 1153.96
S 0 114.50 4236.50 0.00
H 0 404.73 25437.35 19501.04
T 0 79.00 5206.71 5206.71
6807 5683.76 411063.97 0.00
Other 0 609.75 16978.87 0.00
-------------------------------------------------
Total 6807 7644.24 528592.97 99319.04
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 0 697.00 60666.26 73457.33
D 0 55.50 5003.31 1153.96
S 0 114.50 4236.50 0.00
H 0 404.73 25437.35 19501.04
T 0 79.00 5206.71 5206.71
9936 14617.01 919029.82 0.00
Other 0 609.75 16978.87 0.00
-------------------------------------------------
Total 9936 16577.49 1036558.82 99319.04
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 1083.00 63545.04 76336.11
D 0 55.50 5003.31 1153.96
S 0 114.50 4236.50 0.00
H 0 404.73 25437.35 19501.04
T 0 79.00 5206.71 5206.71
177 14983.26 949879.01 0.00
Other 0 609.75 16978.87 0.00
-------------------------------------------------
Total 201 17329.74 1070286.79 102197.82
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 366 1607.00 98669.26 117303.77
D 0 55.50 5003.31 1153.96
S 0 114.50 4236.50 0.00
H 0 404.73 25437.35 19501.04
T 0 79.00 5206.71 5206.71
5906 24898.76 1613409.75 3036.00
Other 0 609.75 16978.87 0.00
-------------------------------------------------
Total 6272 27769.24 1768941.75 146201.48
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 1608.50 98771.08 117303.77
D 0 55.50 5003.31 1153.96
S 0 114.50 4236.50 0.00
H 0 404.73 25437.35 19501.04
T 0 79.00 5206.71 5206.71
4318 32255.26 2111771.87 3036.00
Other 0 609.75 16978.87 0.00
-------------------------------------------------
Total 4319 35127.24 2267405.69 146201.48
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 1744.25 103063.82 121596.51
D 0 55.50 5003.31 1153.96
S 0 114.50 4236.50 0.00
H 0 404.73 25437.35 19501.04
T 0 79.00 5206.71 5206.71
484 33324.01 2187810.03 3036.00
Other 0 609.75 16978.87 0.00
-------------------------------------------------
Total 511 36331.74 2347736.59 150494.22
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 103 1894.95 114911.08 131328.46
D 1 59.00 5240.89 1153.96
S 0 114.50 4236.50 0.00
H 339 994.23 61655.49 19501.04
T 0 79.00 5206.71 5206.71
2034 37387.18 2425281.45 3276.00
Other 0 609.75 16978.87 0.00
-------------------------------------------------
Total 2477 41138.61 2633510.99 160466.17
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 40 1937.26 119605.98 134740.43
D 0 59.00 5240.89 1153.96
S 0 114.50 4236.50 0.00
H 0 994.23 61655.49 19501.04
T 0 79.00 5206.71 5206.71
1277 38621.82 2501246.38 7215.00
Other 57 700.25 24918.62 205.50
-------------------------------------------------
Total 1374 42506.06 2722110.57 168022.64
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 106 2067.12 147596.42 149711.42
D 1 60.00 5503.39 1298.34
S 2 117.00 4734.80 2.65
H 0 994.23 61655.49 19501.04
T 0 79.00 5206.71 5206.71
2811 44342.46 2802722.63 7507.90
Other 0 700.25 24918.62 205.50
-------------------------------------------------
Total 2920 48360.06 3052338.06 183433.56
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 2079.62 148416.44 150396.22
D 4 65.50 5853.39 1298.34
S 0 117.00 4734.80 2.65
H 10 1009.23 63023.49 19501.04
T 0 79.00 5206.71 5206.71
3752 46865.08 2968986.33 7507.90
Other 0 700.25 24918.62 205.50
-------------------------------------------------
Total 3779 50915.68 3221139.78 184118.36
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 2079.62 148416.44 150396.22
D 0 65.50 5853.39 1298.34
S 2 269.00 4945.56 213.41
H 0 1009.23 63023.49 19501.04
T 3 88.50 5708.53 5708.53
699 48532.33 3077201.98 58252.34
Other 0 700.25 24918.62 205.50
-------------------------------------------------
Total 704 52744.43 3330068.01 235575.38
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 2079.62 148416.44 150396.22
D 0 65.50 5853.39 1298.34
S 0 269.00 4945.56 213.41
H 0 1009.23 63023.49 19501.04
T 0 88.50 5708.53 5708.53
23 48577.33 3079131.29 58252.34
Other 0 700.25 24918.62 205.50
-------------------------------------------------
Total 23 52789.43 3331997.32 235575.38