CMS/EIP Fiscal Report Statewide
Services beginning 01/01/2009 ending 03/31/2009 Date of Report:05/18/2009 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 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
AUDE-92553-PURE TONE AUDIOMETRY AIR & BONE 1 1.00 16.30 16.30
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 92 92.00 812.36 8.83
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 66 66.00 712.80 10.80
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 94 94.00 2048.26 21.79
EVAL-EVAL-DEVELOPMENTAL EVALUATION 8 11.50 575.00 50.00
EXIT-EXIT-TRANSITION ASSESSMENT 6 11.00 675.00 61.36
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 19 33.00 2475.00 75.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 14 23.00 2193.76 95.38
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 11 18.00 1350.00 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 16 24.00 2015.63 83.98
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 251 417.50 31312.50 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 168 262.67 19699.88 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 40 62.50 4687.50 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 135 238.90 13231.13 55.38
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 102 150.17 12087.40 80.49
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 1 1.00 48.50 48.50
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 3 3.00 147.40 49.13
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 1 1.00 48.50 48.50
SCREEN-T1023-INTERDISCIPLINARY SCREENING 1 1.00 50.00 50.00
SPCH-92506-SPEECH EVAL BY LICENSED SLP 9 9.00 436.50 48.50
Subtotal (Total Children Is Unduplicated) 491 1574.24 98091.73 62.31
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 5 5.25 262.50 50.00
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 1 0.75 37.50 50.00
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 2 5.00 125.00 25.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 42 190.91 10150.63 53.17
OCCT-97530-OT SESSION BY LICENSED OT 39 237.00 16087.56 67.88
PHY-97110-PT SESSION BY LICENSED PT 11 28.00 1900.64 67.88
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 53 207.89 14113.16 67.89
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 1 50.00 42.50 0.85
Subtotal (Total Children Is Unduplicated) 141 724.80 42719.49 58.94
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Total 2377.04 143715.72 60.46
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Number of Children (Unduplicated) With at Least One Service 663
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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
120 126.25 7068.50 0.00
Other 23 31.00 2091.00 0.00
-------------------------------------------------
Total 168 178.25 9949.50 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
5 130.75 7235.00 0.00
Other 0 31.00 2091.00 0.00
-------------------------------------------------
Total 5 182.75 10116.00 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 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
0 130.75 7235.00 0.00
Other 91 122.00 3444.04 0.00
-------------------------------------------------
Total 91 273.75 11469.04 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 7 6.50 797.50 1442.12
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
2 132.25 7328.00 0.00
Other 0 122.00 3444.04 0.00
-------------------------------------------------
Total 9 281.75 12359.54 1442.12
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 6.50 797.50 1442.12
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
13 145.25 8169.27 0.00
Other 0 122.00 3444.04 0.00
-------------------------------------------------
Total 13 294.75 13200.81 1442.12
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 6.50 797.50 1442.12
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
428 709.50 40261.49 0.00
Other 0 122.00 3444.04 0.00
-------------------------------------------------
Total 428 859.00 45293.03 1442.12
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 0 6.50 797.50 1442.12
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
1 709.75 40270.74 0.00
Other 0 122.00 3444.04 0.00
-------------------------------------------------
Total 1 859.25 45302.28 1442.12
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 6.50 797.50 1442.12
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
315 1022.50 61442.07 0.00
Other 0 122.00 3444.04 0.00
-------------------------------------------------
Total 315 1172.00 66473.61 1442.12
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 6.50 797.50 1442.12
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
324 1608.00 101815.32 0.00
Other 0 122.00 3444.04 0.00
-------------------------------------------------
Total 324 1757.50 106846.86 1442.12
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 6.50 797.50 1442.12
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
11 1618.50 102500.36 0.00
Other 0 122.00 3444.04 0.00
-------------------------------------------------
Total 11 1768.00 107531.90 1442.12
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 1 7.39 857.91 1502.53
D 0 1.00 50.00 0.00
S 0 20.00 740.00 0.00
H 47 75.50 4636.65 0.00
T 0 0.00 0.00 0.00
125 1846.66 117223.82 173.78
Other 0 122.00 3444.04 0.00
-------------------------------------------------
Total 173 2072.55 126952.42 1676.31
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 9.63 1007.55 1652.17
D 0 1.00 50.00 0.00
S 0 20.00 740.00 0.00
H 0 75.50 4636.65 0.00
T 0 0.00 0.00 0.00
45 1898.66 119870.82 173.78
Other 8 138.00 4527.04 0.00
-------------------------------------------------
Total 56 2142.79 130832.06 1825.95
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 45.13 5146.71 3333.36
D 0 1.00 50.00 0.00
S 0 20.00 740.00 0.00
H 0 75.50 4636.65 0.00
T 0 0.00 0.00 0.00
114 2066.16 126591.82 173.78
Other 0 138.00 4527.04 0.00
-------------------------------------------------
Total 146 2345.79 141692.22 3507.14
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 45.13 5146.71 3333.36
D 0 1.00 50.00 0.00
S 0 20.00 740.00 0.00
H 0 75.50 4636.65 0.00
T 0 0.00 0.00 0.00
22 2097.41 128615.32 173.78
Other 0 138.00 4527.04 0.00
-------------------------------------------------
Total 22 2377.04 143715.72 3507.14