CMS/EIP Fiscal Report Statewide
Services beginning 01/01/2009 ending 03/31/2009 Date of Report:05/18/2009 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 3 6.50 240.50 37.00
Subtotal (Total Children Is Unduplicated) 3 6.50 240.50 37.00
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Screening, Eval, and Assessment,Class #02
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 2 2.00 17.66 8.83
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 2 2.00 21.60 10.80
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 2 2.00 43.58 21.79
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 1 1.00 28.28 28.28
EVAL-EVAL-DEVELOPMENTAL EVALUATION 1 1.00 50.00 50.00
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 4 6.00 450.00 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 3 4.50 337.50 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 3 4.50 249.75 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 116 175.10 13079.38 74.70
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 53 81.24 6345.86 78.11
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 34 44.50 3311.00 74.40
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 80 140.67 7807.22 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 42 55.24 5042.75 91.29
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 1 1.00 185.00 185.00
SPCH-92506-SPEECH EVAL BY LICENSED SLP 2 2.00 97.00 48.50
Subtotal (Total Children Is Unduplicated) 178 522.75 37066.58 70.91
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EI Services,Class #03
PHY-97110-PT SESSION BY LICENSED PT 1 2.00 135.76 67.88
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 1 1.00 67.88 67.88
Subtotal (Total Children Is Unduplicated) 1 3.00 203.64 67.88
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Total 532.25 37510.72 70.48
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Number of Children (Unduplicated) With at Least One Service 180
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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 6 4.25 157.25 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
35 42.25 2707.25 0.00
Other 12 18.00 1291.50 0.00
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Total 53 64.50 4156.00 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 4.25 157.25 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
1 44.25 2857.25 0.00
Other 0 18.00 1291.50 0.00
-------------------------------------------------
Total 1 66.50 4306.00 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 4.25 157.25 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
0 44.25 2857.25 0.00
Other 4 22.00 1361.20 0.00
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Total 4 70.50 4375.70 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 2 2.00 240.50 427.12
D 0 0.00 0.00 0.00
S 0 4.25 157.25 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
0 44.25 2857.25 0.00
Other 0 22.00 1361.20 0.00
-------------------------------------------------
Total 2 72.50 4616.20 427.12
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 2.00 240.50 427.12
D 0 0.00 0.00 0.00
S 0 4.25 157.25 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
2 46.25 3007.25 0.00
Other 0 22.00 1361.20 0.00
-------------------------------------------------
Total 2 74.50 4766.20 427.12
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 2.00 240.50 427.12
D 0 0.00 0.00 0.00
S 0 4.25 157.25 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
45 110.75 7661.17 0.00
Other 0 22.00 1361.20 0.00
-------------------------------------------------
Total 45 139.00 9420.12 427.12
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 2.00 240.50 427.12
D 0 0.00 0.00 0.00
S 0 4.25 157.25 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
21 134.75 9434.67 0.00
Other 0 22.00 1361.20 0.00
-------------------------------------------------
Total 21 163.00 11193.62 427.12
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 2.00 240.50 427.12
D 0 0.00 0.00 0.00
S 0 4.25 157.25 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
144 374.75 25611.42 0.00
Other 0 22.00 1361.20 0.00
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Total 144 403.00 27370.37 427.12
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 2.00 240.50 427.12
D 0 0.00 0.00 0.00
S 0 4.25 157.25 0.00
H 11 17.00 1060.50 0.00
T 0 0.00 0.00 0.00
23 408.75 27889.67 0.00
Other 0 22.00 1361.20 0.00
-------------------------------------------------
Total 34 454.00 30709.12 427.12
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 3 6.15 518.68 705.30
D 0 0.00 0.00 0.00
S 0 4.25 157.25 0.00
H 0 17.00 1060.50 0.00
T 0 0.00 0.00 0.00
0 408.75 27889.67 0.00
Other 3 28.00 1772.20 0.00
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Total 6 464.15 31398.30 705.30
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 5 12.65 2159.33 1638.18
D 0 0.00 0.00 0.00
S 0 4.25 157.25 0.00
H 0 17.00 1060.50 0.00
T 0 0.00 0.00 0.00
16 426.75 29239.67 0.00
Other 0 28.00 1772.20 0.00
-------------------------------------------------
Total 21 488.65 34388.95 1638.18
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 12.65 2159.33 1638.18
D 0 0.00 0.00 0.00
S 0 4.25 157.25 0.00
H 0 17.00 1060.50 0.00
T 0 0.00 0.00 0.00
23 467.35 32157.80 0.00
Other 0 28.00 1772.20 0.00
-------------------------------------------------
Total 23 529.25 37307.08 1638.18
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 12.65 2159.33 1638.18
D 0 0.00 0.00 0.00
S 0 4.25 157.25 0.00
H 0 17.00 1060.50 0.00
T 0 0.00 0.00 0.00
2 470.35 32361.44 0.00
Other 0 28.00 1772.20 0.00
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Total 2 532.25 37510.72 1638.18