CMS/EIP Fiscal Report Statewide
Services beginning 10/01/2008 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
TCM-T1017TL-TARGETED CASE MANAGEMENT 8 14.50 453.25 31.26
Subtotal (Total Children Is Unduplicated) 8 14.50 453.25 31.26
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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) 8 8.00 70.64 8.83
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 4 4.00 43.20 10.80
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 6 6.00 130.74 21.79
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 7 8.00 600.00 75.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 4 7.00 525.00 75.00
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 6 8.50 611.00 71.88
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 7 8.50 471.75 55.50
IPDEI-IPDEI_NM-INITIAL PSYCH & DEV EVAL BY NON-MED PR 2 2.00 97.00 48.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 122 179.03 13230.94 73.90
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 44 62.16 4662.50 75.01
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 45 57.00 4222.00 74.07
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 50 75.50 4190.25 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 52 66.16 5759.39 87.05
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 1 1.00 185.00 185.00
SCREEN-T1023-INTERDISCIPLINARY SCREENING 3 3.00 150.00 50.00
SPCH-92506-SPEECH EVAL BY LICENSED SLP 2 1.30 63.50 48.85
Subtotal (Total Children Is Unduplicated) 193 500.15 35109.15 70.20
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EI Services,Class #03
PHY-97110-PT SESSION BY LICENSED PT 1 1.50 101.82 67.88
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 3 143.00 71.50 0.50
Subtotal (Total Children Is Unduplicated) 4 144.50 173.32 1.20
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Total 659.15 35735.72 54.21
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Number of Children (Unduplicated) With at Least One Service 198
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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 0 0.00 0.00 0.00
D 0 0.00 0.00 0.00
S 0 0.00 0.00 0.00
H 3 4.00 300.00 0.00
T 0 0.00 0.00 0.00
2 3.00 195.75 0.00
Other 9 12.50 820.50 0.00
-------------------------------------------------
Total 14 19.50 1316.25 0.00
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 0.00 0.00 0.00
D 0 0.00 0.00 0.00
S 0 0.00 0.00 0.00
H 0 4.00 300.00 0.00
T 0 0.00 0.00 0.00
7 9.75 529.75 0.00
Other 0 12.50 820.50 0.00
-------------------------------------------------
Total 7 26.25 1650.25 0.00
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 0.00 0.00 0.00
D 0 0.00 0.00 0.00
S 0 0.00 0.00 0.00
H 0 4.00 300.00 0.00
T 0 0.00 0.00 0.00
0 9.75 529.75 0.00
Other 14 26.50 1014.65 0.00
-------------------------------------------------
Total 14 40.25 1844.40 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 4 5.00 485.00 591.30
D 0 0.00 0.00 0.00
S 0 0.00 0.00 0.00
H 0 4.00 300.00 0.00
T 0 0.00 0.00 0.00
0 9.75 529.75 0.00
Other 0 26.50 1014.65 0.00
-------------------------------------------------
Total 4 45.25 2329.40 591.30
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 5.00 485.00 591.30
D 0 0.00 0.00 0.00
S 0 0.00 0.00 0.00
H 0 4.00 300.00 0.00
T 0 0.00 0.00 0.00
3 12.75 735.25 0.00
Other 0 26.50 1014.65 0.00
-------------------------------------------------
Total 3 48.25 2534.90 591.30
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 5.00 485.00 591.30
D 0 0.00 0.00 0.00
S 0 0.00 0.00 0.00
H 0 4.00 300.00 0.00
T 0 0.00 0.00 0.00
34 55.25 3728.49 0.00
Other 0 26.50 1014.65 0.00
-------------------------------------------------
Total 34 90.75 5528.14 591.30
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 0 5.00 485.00 591.30
D 0 0.00 0.00 0.00
S 0 0.00 0.00 0.00
H 0 4.00 300.00 0.00
T 0 0.00 0.00 0.00
76 131.75 9226.49 0.00
Other 0 26.50 1014.65 0.00
-------------------------------------------------
Total 76 167.25 11026.14 591.30
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 5.00 485.00 591.30
D 0 0.00 0.00 0.00
S 0 0.00 0.00 0.00
H 0 4.00 300.00 0.00
T 0 0.00 0.00 0.00
145 366.25 25839.24 0.00
Other 0 26.50 1014.65 0.00
-------------------------------------------------
Total 145 401.75 27638.89 591.30
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 0 5.00 485.00 591.30
D 0 0.00 0.00 0.00
S 0 0.00 0.00 0.00
H 7 14.50 999.75 0.00
T 0 0.00 0.00 0.00
26 536.50 27401.24 0.00
Other 0 26.50 1014.65 0.00
-------------------------------------------------
Total 33 582.50 29900.64 591.30
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 0 5.00 485.00 591.30
D 0 0.00 0.00 0.00
S 0 0.00 0.00 0.00
H 0 14.50 999.75 0.00
T 0 0.00 0.00 0.00
2 540.50 27662.24 0.00
Other 2 29.50 1210.40 0.00
-------------------------------------------------
Total 4 589.50 30357.39 591.30
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 2 7.00 1141.26 958.80
D 0 0.00 0.00 0.00
S 0 0.00 0.00 0.00
H 0 14.50 999.75 0.00
T 0 0.00 0.00 0.00
32 576.62 30136.37 0.00
Other 0 29.50 1210.40 0.00
-------------------------------------------------
Total 34 627.62 33487.78 958.80
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 7.00 1141.26 958.80
D 0 0.00 0.00 0.00
S 0 0.00 0.00 0.00
H 0 14.50 999.75 0.00
T 0 0.00 0.00 0.00
17 608.15 32384.31 0.00
Other 0 29.50 1210.40 0.00
-------------------------------------------------
Total 17 659.15 35735.72 958.80