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: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 4 2.00 74.00 37.00
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 6 6.00 0.00 0.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 3 4.00 148.00 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 54 120.50 4403.00 36.54
TCON-TCON-TRANSITION CONFERENCE 1 1.00 0.00 0.00
Subtotal (Total Children Is Unduplicated) 62 133.50 4625.00 34.64
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Screening, Eval, and Assessment,Class #02
AUDE-92552-PURE TONE AUDIOMETRY -AIR ONLY 9 9.00 95.58 10.62
AUDE-92553-PURE TONE AUDIOMETRY AIR & BONE 3 3.00 48.90 16.30
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 105 105.00 979.32 9.33
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 98 100.00 1111.20 11.11
AUDE-92568-ACOUSTIC REFLEX TESTING (MEMR) 6 6.00 50.64 8.44
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 105 105.00 2316.16 22.06
AUDE-92585-AUD EVOKED RESPONSE (DIAG) 3 4.00 217.52 54.38
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 5 3.84 109.00 28.39
AUDE-92588-OTOACOUSTIC EMISSIONS (COMP) 15 15.00 477.15 31.81
EVAL-EVAL-DEVELOPMENTAL EVALUATION 13 22.00 1250.00 56.82
EXIT-EXIT-TRANSITION ASSESSMENT 1 1.00 50.00 50.00
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 54 83.58 6215.50 74.37
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 17 26.08 1903.00 72.97
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 27 33.00 2422.00 73.39
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 39 63.50 5365.63 84.50
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 15 21.96 1635.50 74.48
IPDEI-IPDEI_NM-INITIAL PSYCH & DEV EVAL BY NON-MED PR 6 8.50 457.75 53.85
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 426 618.14 45856.71 74.18
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 203 317.57 23951.03 75.42
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 183 245.25 18239.06 74.37
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 139 203.41 11482.46 56.45
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 133 184.60 15215.68 82.43
MED-99202-OUTPATIENT VISIT, NEW, 20 MINS 3 3.00 81.66 27.22
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 3 3.00 555.00 185.00
MED-99204-OUTPATIENT VISIT, NEW, 45 MINS 11 11.00 629.97 57.27
MED-99205-OUTPATIENT VISIT, NEW, 60 MINS 2 2.00 145.56 72.78
MED-99214-OUTPATIENT VISIT, EST, 25 MINS 4 4.00 138.00 34.50
MED-99215-OUTPATIENT VISIT, EST, 40 MINS 2 2.00 100.30 50.15
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 17 18.00 873.00 48.50
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 48 48.44 2623.90 54.17
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 11 13.66 662.50 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 23 23.00 1094.23 47.58
SCREEN-T1023-INTERDISCIPLINARY SCREENING 4 4.00 200.00 50.00
SPCH-92506-SPEECH EVAL BY LICENSED SLP 56 56.79 2724.14 47.97
Subtotal (Total Children Is Unduplicated) 872 2368.32 149278.05 63.03
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 5 32.00 13301.92 415.69
AUD-HA_FUP-AUDIOLOGY SERVICES 2 1.90 94.84 49.92
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 3 3.50 155.00 44.29
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 1 1.50 75.00 50.00
CONOF-CONOF-CONSULT, OT, FACE TO FACE 2 2.50 125.00 50.00
CONPF-CONPF-CONSULT, PT, FACE TO FACE 2 1.25 62.50 50.00
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 1 1.50 75.00 50.00
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 1 2.00 50.00 25.00
EIIF-96154-HEALTH AND BEHAVIOR INTERVENTION 1 4.50 225.00 50.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 99 368.54 20387.28 55.32
OCCT-97530-OT SESSION BY LICENSED OT 534 2198.47 150812.80 68.60
OCCT-97530HM-OT SESSION BY OT ASST 20 43.25 2349.34 54.32
PHY-97110-PT SESSION BY LICENSED PT 536 2063.26 141026.29 68.35
PHY-97110HM-PT SESSION BY PT ASST 12 43.50 2369.70 54.48
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 943 3539.94 242206.67 68.42
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 6 11.00 597.52 54.32
SPL-92508-GROUP SPL SESSION PER CHILD 10 25.75 339.90 13.20
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 19 1012.00 531.40 0.53
Subtotal (Total Children Is Unduplicated) 1610 9356.36 574785.16 61.43
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Total 11858.18 728688.21 61.45
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Number of Children (Unduplicated) With at Least One Service 2240
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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 26 38.00 2460.38 0.00
T 5 8.00 543.04 543.04
182 270.30 14318.18 0.00
Other 45 51.50 3375.63 0.00
-------------------------------------------------
Total 258 367.80 20697.23 543.04
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 38.00 2460.38 0.00
T 0 8.00 543.04 543.04
58 325.05 16553.43 0.00
Other 0 51.50 3375.63 0.00
-------------------------------------------------
Total 58 422.55 22932.48 543.04
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 38.00 2460.38 0.00
T 0 8.00 543.04 543.04
0 325.05 16553.43 0.00
Other 67 118.50 4357.11 0.00
-------------------------------------------------
Total 67 489.55 23913.96 543.04
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 8 20.50 1531.90 1508.14
D 0 0.00 0.00 0.00
S 0 0.00 0.00 0.00
H 41 121.78 7902.22 5525.36
T 0 8.00 543.04 543.04
0 325.05 16553.43 0.00
Other 0 118.50 4357.11 0.00
-------------------------------------------------
Total 49 593.83 30887.70 7576.54
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 20.50 1531.90 1508.14
D 0 0.00 0.00 0.00
S 0 0.00 0.00 0.00
H 0 121.78 7902.22 5525.36
T 0 8.00 543.04 543.04
1414 1101.05 68676.31 0.00
Other 0 118.50 4357.11 0.00
-------------------------------------------------
Total 1414 1369.83 83010.58 7576.54
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 20.50 1531.90 1508.14
D 0 0.00 0.00 0.00
S 0 0.00 0.00 0.00
H 0 121.78 7902.22 5525.36
T 0 8.00 543.04 543.04
2147 2923.05 182026.81 0.00
Other 0 118.50 4357.11 0.00
-------------------------------------------------
Total 2147 3191.83 196361.08 7576.54
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 24 406.50 4410.68 4386.92
D 0 0.00 0.00 0.00
S 0 0.00 0.00 0.00
H 0 121.78 7902.22 5525.36
T 0 8.00 543.04 543.04
75 3076.55 192319.59 0.00
Other 0 118.50 4357.11 0.00
-------------------------------------------------
Total 99 3731.33 209532.64 10455.32
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 2 410.00 4655.38 4742.29
D 0 0.00 0.00 0.00
S 0 0.00 0.00 0.00
H 0 121.78 7902.22 5525.36
T 0 8.00 543.04 543.04
1493 5574.80 352230.22 0.00
Other 0 118.50 4357.11 0.00
-------------------------------------------------
Total 1495 6233.08 369687.97 10810.69
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 0 410.00 4655.38 4742.29
D 0 0.00 0.00 0.00
S 0 0.00 0.00 0.00
H 0 121.78 7902.22 5525.36
T 0 8.00 543.04 543.04
624 6654.80 426522.34 0.00
Other 0 118.50 4357.11 0.00
-------------------------------------------------
Total 624 7313.08 443980.09 10810.69
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 26 544.25 8846.30 8933.21
D 0 0.00 0.00 0.00
S 0 0.00 0.00 0.00
H 0 121.78 7902.22 5525.36
T 0 8.00 543.04 543.04
134 6915.55 452780.48 0.00
Other 0 118.50 4357.11 0.00
-------------------------------------------------
Total 160 7708.08 474429.15 15001.61
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 21 575.34 11906.40 11993.31
D 0 0.00 0.00 0.00
S 0 0.00 0.00 0.00
H 88 285.03 18075.24 5525.36
T 0 8.00 543.04 543.04
648 8126.34 528584.55 0.00
Other 0 118.50 4357.11 0.00
-------------------------------------------------
Total 757 9113.21 563466.34 18061.71
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 16 595.53 13578.31 13415.22
D 0 0.00 0.00 0.00
S 0 0.00 0.00 0.00
H 0 285.03 18075.24 5525.36
T 0 8.00 543.04 543.04
399 8547.19 553058.62 0.00
Other 37 178.50 9115.36 0.00
-------------------------------------------------
Total 452 9614.25 594370.57 19483.62
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 20 627.53 19450.71 16458.86
D 0 0.00 0.00 0.00
S 0 0.00 0.00 0.00
H 0 285.03 18075.24 5525.36
T 0 8.00 543.04 543.04
595 9560.62 615218.54 0.00
Other 0 178.50 9115.36 0.00
-------------------------------------------------
Total 615 10659.68 662402.89 22527.26
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 8 632.53 19770.73 16778.88
D 0 0.00 0.00 0.00
S 0 0.00 0.00 0.00
H 0 285.03 18075.24 5525.36
T 0 8.00 543.04 543.04
835 10230.87 656962.93 0.00
Other 0 178.50 9115.36 0.00
-------------------------------------------------
Total 843 11334.93 704467.30 22847.28
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 0 632.53 19770.73 16778.88
D 0 0.00 0.00 0.00
S 1 150.00 75.00 75.00
H 0 285.03 18075.24 5525.36
T 1 9.50 644.86 644.86
168 10602.62 681007.02 18504.00
Other 0 178.50 9115.36 0.00
-------------------------------------------------
Total 170 11858.18 728688.21 41528.10