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: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 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 62 135.00 4856.25 35.97
TCON-TCON-TRANSITION CONFERENCE 1 1.00 0.00 0.00
Subtotal (Total Children Is Unduplicated) 70 148.00 5078.25 34.31
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Screening, Eval, and Assessment,Class #02
AUDE-92552-PURE TONE AUDIOMETRY -AIR ONLY 11 11.00 116.82 10.62
AUDE-92553-PURE TONE AUDIOMETRY AIR & BONE 3 3.00 48.90 16.30
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 113 113.00 1049.96 9.29
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 102 104.00 1154.40 11.10
AUDE-92568-ACOUSTIC REFLEX TESTING (MEMR) 6 6.00 50.64 8.44
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 111 111.00 2446.90 22.04
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 18 27.00 1500.00 55.56
EXIT-EXIT-TRANSITION ASSESSMENT 1 1.00 50.00 50.00
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 61 91.58 6815.50 74.42
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 21 33.08 2428.00 73.40
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 33 41.50 3033.00 73.08
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 40 64.50 5440.63 84.35
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 22 30.46 2107.25 69.18
IPDEI-IPDEI_NM-INITIAL PSYCH & DEV EVAL BY NON-MED PR 8 10.50 554.75 52.83
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 548 797.17 59087.65 74.12
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 247 379.73 28613.53 75.35
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 228 302.25 22461.06 74.31
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 190 280.41 15755.96 56.19
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 186 252.26 21087.57 83.59
MED-99202-OUTPATIENT VISIT, NEW, 20 MINS 3 3.00 81.66 27.22
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 6 6.00 1110.00 185.00
MED-99204-OUTPATIENT VISIT, NEW, 45 MINS 11 11.00 629.97 57.27
MED-99205-OUTPATIENT VISIT, NEW, 60 MINS 4 4.00 291.12 72.78
MED-99214-OUTPATIENT VISIT, EST, 25 MINS 4 4.00 138.00 34.50
MED-99215-OUTPATIENT VISIT, EST, 40 MINS 5 5.00 250.75 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 7 7.00 350.00 50.00
SPCH-92506-SPEECH EVAL BY LICENSED SLP 58 58.09 2787.64 47.99
Subtotal (Total Children Is Unduplicated) 1072 2883.47 185498.96 64.33
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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 537 2064.76 141128.11 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 22 1155.00 602.90 0.52
Subtotal (Total Children Is Unduplicated) 1614 9500.86 574958.48 60.52
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Total 12532.33 765535.69 61.08
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Number of Children (Unduplicated) With at Least One Service 2445
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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 29 42.00 2760.38 0.00
T 5 8.00 543.04 543.04
184 273.30 14513.93 0.00
Other 54 64.00 4196.13 0.00
-------------------------------------------------
Total 272 387.30 22013.48 543.04
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 42.00 2760.38 0.00
T 0 8.00 543.04 543.04
65 334.80 17083.18 0.00
Other 0 64.00 4196.13 0.00
-------------------------------------------------
Total 65 448.80 24582.73 543.04
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 42.00 2760.38 0.00
T 0 8.00 543.04 543.04
0 334.80 17083.18 0.00
Other 81 145.00 5371.76 0.00
-------------------------------------------------
Total 81 529.80 25758.36 543.04
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 16 30.50 2582.65 2718.02
D 0 0.00 0.00 0.00
S 0 0.00 0.00 0.00
H 41 125.78 8202.22 5525.36
T 0 8.00 543.04 543.04
0 334.80 17083.18 0.00
Other 0 145.00 5371.76 0.00
-------------------------------------------------
Total 57 644.08 33782.85 8786.42
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 30.50 2582.65 2718.02
D 0 0.00 0.00 0.00
S 0 0.00 0.00 0.00
H 0 125.78 8202.22 5525.36
T 0 8.00 543.04 543.04
1427 1123.80 69957.57 0.00
Other 0 145.00 5371.76 0.00
-------------------------------------------------
Total 1427 1433.08 86657.24 8786.42
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 30.50 2582.65 2718.02
D 0 0.00 0.00 0.00
S 0 0.00 0.00 0.00
H 0 125.78 8202.22 5525.36
T 0 8.00 543.04 543.04
2181 2988.30 186301.31 0.00
Other 0 145.00 5371.76 0.00
-------------------------------------------------
Total 2181 3297.58 203000.98 8786.42
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 24 416.50 5461.43 5596.80
D 0 0.00 0.00 0.00
S 0 0.00 0.00 0.00
H 0 125.78 8202.22 5525.36
T 0 8.00 543.04 543.04
75 3141.80 196594.09 0.00
Other 0 145.00 5371.76 0.00
-------------------------------------------------
Total 99 3837.08 216172.54 11665.20
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 2 420.00 5706.13 5952.17
D 0 0.00 0.00 0.00
S 0 0.00 0.00 0.00
H 0 125.78 8202.22 5525.36
T 0 8.00 543.04 543.04
1569 5716.55 362002.72 0.00
Other 0 145.00 5371.76 0.00
-------------------------------------------------
Total 1571 6415.33 381825.87 12020.57
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 0 420.00 5706.13 5952.17
D 0 0.00 0.00 0.00
S 0 0.00 0.00 0.00
H 0 125.78 8202.22 5525.36
T 0 8.00 543.04 543.04
769 7031.05 452907.59 0.00
Other 0 145.00 5371.76 0.00
-------------------------------------------------
Total 769 7729.83 472730.74 12020.57
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 26 554.25 9897.05 10143.09
D 0 0.00 0.00 0.00
S 0 0.00 0.00 0.00
H 0 125.78 8202.22 5525.36
T 0 8.00 543.04 543.04
134 7291.80 479165.73 0.00
Other 0 145.00 5371.76 0.00
-------------------------------------------------
Total 160 8124.83 503179.80 16211.49
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 21 585.34 12957.15 13203.19
D 0 0.00 0.00 0.00
S 0 0.00 0.00 0.00
H 95 299.53 19074.99 5525.36
T 0 8.00 543.04 543.04
674 8672.84 556531.80 0.00
Other 0 145.00 5371.76 0.00
-------------------------------------------------
Total 790 9710.71 594478.74 19271.59
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 16 605.53 14629.06 14625.10
D 0 0.00 0.00 0.00
S 0 0.00 0.00 0.00
H 0 299.53 19074.99 5525.36
T 0 8.00 543.04 543.04
401 9097.69 581266.87 0.00
Other 39 208.00 10325.76 0.00
-------------------------------------------------
Total 456 10218.75 625839.72 20693.50
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 22 639.53 21157.72 18036.24
D 0 0.00 0.00 0.00
S 0 0.00 0.00 0.00
H 0 299.53 19074.99 5525.36
T 0 8.00 543.04 543.04
627 10147.24 645900.92 0.00
Other 0 208.00 10325.76 0.00
-------------------------------------------------
Total 649 11302.30 697002.43 24104.64
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 8 644.53 21477.74 18356.26
D 0 0.00 0.00 0.00
S 0 0.00 0.00 0.00
H 0 299.53 19074.99 5525.36
T 0 8.00 543.04 543.04
852 10849.02 689893.25 0.00
Other 0 208.00 10325.76 0.00
-------------------------------------------------
Total 860 12009.08 741314.78 24424.66
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 0 644.53 21477.74 18356.26
D 0 0.00 0.00 0.00
S 1 150.00 75.00 75.00
H 0 299.53 19074.99 5525.36
T 1 9.50 644.86 644.86
168 11220.77 713937.34 18504.00
Other 0 208.00 10325.76 0.00
-------------------------------------------------
Total 170 12532.33 765535.69 43105.48