CMS/EIP Fiscal Report Statewide
Services beginning 10/01/2008 ending 12/31/2008 Date of Report:02/17/2009 Page: 1
Agency Filter:EIP DEI DEIP
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 1 1.00 10.62 10.62
AUDE-92553-PURE TONE AUDIOMETRY AIR & BONE 1 1.00 16.30 16.30
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 73 73.00 644.59 8.83
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 53 53.00 572.40 10.80
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 72 72.00 1568.88 21.79
EVAL-EVAL-DEVELOPMENTAL EVALUATION 9 11.50 575.00 50.00
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 42 70.08 5256.00 75.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 13 22.08 1656.00 75.00
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 19 25.50 1912.50 75.00
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 4 6.50 360.75 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 339 505.34 37953.18 75.10
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 174 277.24 21186.53 76.42
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 145 204.00 15300.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 126 183.41 10343.21 56.39
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 129 180.77 14928.18 82.58
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 2 2.00 97.00 48.50
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 3 3.00 420.00 140.00
PSTH-97001-EVAL BY LICENSED PT, INITIAL 2 2.00 97.00 48.50
SCREEN-T1023-INTERDISCIPLINARY SCREENING 4 4.00 200.00 50.00
SPCH-92506-SPEECH EVAL BY LICENSED SLP 6 7.00 291.00 41.57
Subtotal (Total Children Is Unduplicated) 625 1814.88 122040.76 67.24
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 1 1.50 75.00 50.00
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 1 1.50 75.00 50.00
CONOF-CONOF-CONSULT, OT, FACE TO FACE 1 2.00 100.00 50.00
CONPF-CONPF-CONSULT, PT, FACE TO FACE 1 1.00 50.00 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-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 50 182.70 11045.49 60.46
OCCT-97530-OT SESSION BY LICENSED OT 49 310.25 21303.81 68.67
PHY-97110-PT SESSION BY LICENSED PT 16 67.00 4849.28 72.38
PHY-97110HM-PT SESSION BY PT ASST 1 1.00 54.32 54.32
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 50 167.20 11669.97 69.80
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 5 135.00 67.50 0.50
Subtotal (Total Children Is Unduplicated) 159 872.65 49415.37 56.63
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Total 2821.03 176081.13 62.42
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Number of Children (Unduplicated) With at Least One Service 807
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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 25 37.00 2392.50 0.00
T 0 0.00 0.00 0.00
9 11.00 655.75 0.00
Other 26 35.50 2296.75 0.00
-------------------------------------------------
Total 60 83.50 5345.00 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 37.00 2392.50 0.00
T 0 0.00 0.00 0.00
50 55.25 2219.00 0.00
Other 0 35.50 2296.75 0.00
-------------------------------------------------
Total 50 127.75 6908.25 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 37.00 2392.50 0.00
T 0 0.00 0.00 0.00
0 55.25 2219.00 0.00
Other 67 102.50 3278.23 0.00
-------------------------------------------------
Total 67 194.75 7889.73 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 3.50 592.50 568.74
D 0 0.00 0.00 0.00
S 0 0.00 0.00 0.00
H 0 37.00 2392.50 0.00
T 0 0.00 0.00 0.00
0 55.25 2219.00 0.00
Other 0 102.50 3278.23 0.00
-------------------------------------------------
Total 4 198.25 8482.23 568.74
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 3.50 592.50 568.74
D 0 0.00 0.00 0.00
S 0 0.00 0.00 0.00
H 0 37.00 2392.50 0.00
T 0 0.00 0.00 0.00
9 64.25 2764.86 0.00
Other 0 102.50 3278.23 0.00
-------------------------------------------------
Total 9 207.25 9028.09 568.74
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 3.50 592.50 568.74
D 0 0.00 0.00 0.00
S 0 0.00 0.00 0.00
H 0 37.00 2392.50 0.00
T 0 0.00 0.00 0.00
428 654.50 38008.05 0.00
Other 0 102.50 3278.23 0.00
-------------------------------------------------
Total 428 797.50 44271.28 568.74
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 2 7.50 892.50 868.74
D 0 0.00 0.00 0.00
S 0 0.00 0.00 0.00
H 0 37.00 2392.50 0.00
T 0 0.00 0.00 0.00
2 658.50 38269.05 0.00
Other 0 102.50 3278.23 0.00
-------------------------------------------------
Total 4 805.50 44832.28 868.74
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 7.50 892.50 868.74
D 0 0.00 0.00 0.00
S 0 0.00 0.00 0.00
H 0 37.00 2392.50 0.00
T 0 0.00 0.00 0.00
589 1495.00 90004.81 0.00
Other 0 102.50 3278.23 0.00
-------------------------------------------------
Total 589 1642.00 96568.04 868.74
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 7.50 892.50 868.74
D 0 0.00 0.00 0.00
S 0 0.00 0.00 0.00
H 0 37.00 2392.50 0.00
T 0 0.00 0.00 0.00
229 1886.00 118484.19 0.00
Other 0 102.50 3278.23 0.00
-------------------------------------------------
Total 229 2033.00 125047.42 868.74
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 0 7.50 892.50 868.74
D 0 0.00 0.00 0.00
S 0 0.00 0.00 0.00
H 0 37.00 2392.50 0.00
T 0 0.00 0.00 0.00
2 1888.00 118619.95 0.00
Other 0 102.50 3278.23 0.00
-------------------------------------------------
Total 2 2035.00 125183.18 868.74
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 38.59 3952.60 3928.84
D 0 0.00 0.00 0.00
S 0 0.00 0.00 0.00
H 88 200.25 12565.52 0.00
T 0 0.00 0.00 0.00
106 2104.25 129235.98 0.00
Other 0 102.50 3278.23 0.00
-------------------------------------------------
Total 215 2445.59 149032.33 3928.84
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 58.78 5624.51 5350.75
D 0 0.00 0.00 0.00
S 0 0.00 0.00 0.00
H 0 200.25 12565.52 0.00
T 0 0.00 0.00 0.00
34 2143.25 131387.06 0.00
Other 37 162.50 8036.48 0.00
-------------------------------------------------
Total 87 2564.78 157613.57 5350.75
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 90.78 11496.91 8394.39
D 0 0.00 0.00 0.00
S 0 0.00 0.00 0.00
H 0 200.25 12565.52 0.00
T 0 0.00 0.00 0.00
168 2321.25 141082.81 0.00
Other 0 162.50 8036.48 0.00
-------------------------------------------------
Total 188 2774.78 173181.72 8394.39
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 90.78 11496.91 8394.39
D 0 0.00 0.00 0.00
S 0 0.00 0.00 0.00
H 0 200.25 12565.52 0.00
T 0 0.00 0.00 0.00
31 2367.50 143982.22 0.00
Other 0 162.50 8036.48 0.00
-------------------------------------------------
Total 31 2821.03 176081.13 8394.39