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: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 2 0.50 18.50 37.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 4 2.50 92.50 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 52 75.00 2793.50 37.25
Subtotal (Total Children Is Unduplicated) 54 78.00 2904.50 37.24
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Screening, Eval, and Assessment,Class #02
AUD-92626-EVAL OF AUD REHAB STATUS 1 1.00 36.07 36.07
AUDE-92552-PURE TONE AUDIOMETRY -AIR ONLY 4 4.00 42.48 10.62
AUDE-92553-PURE TONE AUDIOMETRY AIR & BONE 2 2.00 32.60 16.30
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 115 115.00 1015.45 8.83
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 104 105.00 1134.00 10.80
AUDE-92568-ACOUSTIC REFLEX TESTING (MEMR) 11 11.00 92.84 8.44
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 128 128.00 2789.12 21.79
AUDE-92585-AUD EVOKED RESPONSE (DIAG) 1 1.00 54.38 54.38
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 3 3.00 84.84 28.28
AUDE-92588-OTOACOUSTIC EMISSIONS (COMP) 19 19.00 604.39 31.81
AUDE-V5090-DISPENSING FEE PER HEARING AID 1 2.00 212.00 106.00
EVAL-EVAL-DEVELOPMENTAL EVALUATION 10 14.50 762.50 52.59
EXIT-EXIT-TRANSITION ASSESSMENT 7 14.00 900.00 64.29
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 24 38.50 2846.86 73.94
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 15 23.66 2243.76 94.83
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 12 19.00 1425.00 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 17 24.66 2065.63 83.76
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 14 27.00 1498.50 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 329 521.80 38944.43 74.63
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 187 289.08 21588.07 74.68
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 95 130.83 9732.81 74.39
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 139 246.40 13564.13 55.05
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 110 157.08 12606.40 80.25
MED-99202-OUTPATIENT VISIT, NEW, 20 MINS 1 1.00 27.22 27.22
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 2 2.00 370.00 185.00
MED-99204-OUTPATIENT VISIT, NEW, 45 MINS 16 16.00 916.32 57.27
MED-99205-OUTPATIENT VISIT, NEW, 60 MINS 4 4.00 291.12 72.78
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 3 3.00 315.00 105.00
MED-99215-OUTPATIENT VISIT, EST, 40 MINS 1 1.00 50.15 50.15
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 6 6.00 291.00 48.50
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 43 46.66 2265.10 48.54
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 11 10.67 517.80 48.53
PSTH-97001-EVAL BY LICENSED PT, INITIAL 32 32.64 1583.00 48.50
SCREEN-T1023-INTERDISCIPLINARY SCREENING 1 1.00 50.00 50.00
SPCH-92506-SPEECH EVAL BY LICENSED SLP 75 74.93 3663.61 48.89
VISF-VISF-VISION EVALUATION FUNCTIONAL 1 1.00 70.00 70.00
Subtotal (Total Children Is Unduplicated) 762 2097.41 124686.58 59.45
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 7 12.00 4603.31 383.61
AUD-HA_FUP-AUDIOLOGY SERVICES 1 1.00 50.00 50.00
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 12 12.25 612.50 50.00
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 4 2.75 137.50 50.00
CONOF-CONOF-CONSULT, OT, FACE TO FACE 4 2.25 112.50 50.00
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 4 5.00 250.00 50.00
CONSP-CONSP-CONSULT, SLP, PHONE 1 1.00 25.00 25.00
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 2 5.00 125.00 25.00
EIIF-EIIF_NM-EI INDIVIDUAL SESSION BY NONMED PROF 1 3.00 150.00 50.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 90 410.49 21080.71 51.35
OCCT-97530-OT SESSION BY LICENSED OT 573 2198.60 150943.98 68.65
OCCT-97530HM-OT SESSION BY OT ASST 26 69.75 4229.92 60.64
PHY-97110-PT SESSION BY LICENSED PT 546 2207.48 155148.80 70.28
PHY-97110HM-PT SESSION BY PT ASST 26 80.75 4726.15 58.53
SENS-FM-FM RECEIVER HEARING AID 2 2.00 2989.75 1494.88
SENS-V5264-EARMOLD 4 8.00 144.76 18.10
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 992 3833.63 264232.39 68.92
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 4 5.50 298.76 54.32
SPL-92508-GROUP SPL SESSION PER CHILD 19 45.00 645.38 14.34
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 9 439.00 239.88 0.55
VISN-EIIF_NM-EI VISION SERVICES, IND NONMED 1 9.50 535.00 56.32
Subtotal (Total Children Is Unduplicated) 1683 9353.95 611281.29 65.35
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Total 11529.36 738872.37 64.09
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Number of Children (Unduplicated) With at Least One Service 2225
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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 1 1.00 50.00 0.00
S 24 20.00 740.00 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
342 324.50 23371.92 0.00
Other 27 38.00 2616.00 0.00
-------------------------------------------------
Total 394 383.50 26777.92 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 1.00 50.00 0.00
S 0 20.00 740.00 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
7 332.50 23800.92 0.00
Other 0 38.00 2616.00 0.00
-------------------------------------------------
Total 7 391.50 27206.92 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 1.00 50.00 0.00
S 0 20.00 740.00 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
6 351.50 24057.92 0.00
Other 91 129.00 3969.04 0.00
-------------------------------------------------
Total 97 501.50 28816.96 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 18 48.50 2896.00 3540.62
D 0 1.00 50.00 0.00
S 0 20.00 740.00 0.00
H 47 104.48 7036.70 7036.74
T 0 0.00 0.00 0.00
2 353.00 24150.92 0.00
Other 0 129.00 3969.04 0.00
-------------------------------------------------
Total 67 655.98 38842.66 10577.36
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 11 193.75 3278.00 3922.62
D 0 1.00 50.00 0.00
S 0 20.00 740.00 0.00
H 0 104.48 7036.70 7036.74
T 0 0.00 0.00 0.00
1432 1143.75 77514.31 0.00
Other 0 129.00 3969.04 0.00
-------------------------------------------------
Total 1443 1591.98 92588.05 10959.36
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 9 199.75 3685.28 4329.90
D 0 1.00 50.00 0.00
S 0 20.00 740.00 0.00
H 0 104.48 7036.70 7036.74
T 0 0.00 0.00 0.00
2073 2816.50 190096.64 0.00
Other 0 129.00 3969.04 0.00
-------------------------------------------------
Total 2082 3270.73 205577.66 11366.64
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 20 333.00 6653.89 7298.51
D 0 1.00 50.00 0.00
S 0 20.00 740.00 0.00
H 0 104.48 7036.70 7036.74
T 0 0.00 0.00 0.00
120 3032.50 206650.82 0.00
Other 0 129.00 3969.04 0.00
-------------------------------------------------
Total 140 3619.98 225100.45 14335.25
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 4 337.50 6966.47 7807.16
D 0 1.00 50.00 0.00
S 0 20.00 740.00 0.00
H 0 104.48 7036.70 7036.74
T 0 0.00 0.00 0.00
1358 4819.75 327903.70 0.00
Other 0 129.00 3969.04 0.00
-------------------------------------------------
Total 1362 5411.73 346665.91 14843.90
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 0 337.50 6966.47 7807.16
D 0 1.00 50.00 0.00
S 0 20.00 740.00 0.00
H 0 104.48 7036.70 7036.74
T 0 0.00 0.00 0.00
723 6091.00 415192.54 0.00
Other 0 129.00 3969.04 0.00
-------------------------------------------------
Total 723 6682.98 433954.75 14843.90
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 42 452.00 14230.96 15071.65
D 0 1.00 50.00 0.00
S 0 20.00 740.00 0.00
H 0 104.48 7036.70 7036.74
T 0 0.00 0.00 0.00
198 6539.25 444961.45 0.00
Other 0 129.00 3969.04 0.00
-------------------------------------------------
Total 240 7245.73 470988.15 22108.39
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 1 452.89 14291.37 15132.06
D 0 1.00 50.00 0.00
S 0 20.00 740.00 0.00
H 47 179.98 11673.35 7036.74
T 0 0.00 0.00 0.00
555 7822.79 528530.62 173.78
Other 0 129.00 3969.04 0.00
-------------------------------------------------
Total 603 8605.66 559254.38 22342.58
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 3 455.13 14441.01 15281.70
D 0 1.00 50.00 0.00
S 0 20.00 740.00 0.00
H 0 179.98 11673.35 7036.74
T 0 0.00 0.00 0.00
450 8263.95 553011.82 173.78
Other 8 145.00 5052.04 0.00
-------------------------------------------------
Total 461 9065.06 584968.22 22492.22
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 32 490.63 18580.17 16962.89
D 0 1.00 50.00 0.00
S 0 20.00 740.00 0.00
H 0 179.98 11673.35 7036.74
T 0 0.00 0.00 0.00
635 9536.74 626086.87 173.78
Other 0 145.00 5052.04 0.00
-------------------------------------------------
Total 667 10373.35 662182.43 24173.41
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 7 496.63 19008.81 17391.53
D 0 1.00 50.00 0.00
S 0 20.00 740.00 0.00
H 0 179.98 11673.35 7036.74
T 19 15.50 828.64 828.64
835 10120.75 665021.21 173.78
Other 0 145.00 5052.04 0.00
-------------------------------------------------
Total 861 10978.86 702374.05 25430.69
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 0 496.63 19008.81 17391.53
D 0 1.00 50.00 0.00
S 1 21.50 841.82 101.82
H 0 179.98 11673.35 7036.74
T 2 18.00 980.46 980.46
263 10667.25 701265.89 28370.94
Other 0 145.00 5052.04 0.00
-------------------------------------------------
Total 266 11529.36 738872.37 53881.49