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: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 2 0.50 18.50 37.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 4 2.50 92.50 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 55 81.50 3034.00 37.23
Subtotal (Total Children Is Unduplicated) 57 84.50 3145.00 37.22
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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) 117 117.00 1033.11 8.83
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 106 107.00 1155.60 10.80
AUDE-92568-ACOUSTIC REFLEX TESTING (MEMR) 11 11.00 92.84 8.44
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 130 130.00 2832.70 21.79
AUDE-92585-AUD EVOKED RESPONSE (DIAG) 1 1.00 54.38 54.38
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 4 4.00 113.12 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 15 19.50 1012.50 51.92
EXIT-EXIT-TRANSITION ASSESSMENT 7 14.00 900.00 64.29
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 28 44.50 3296.86 74.09
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 13 20.00 1500.00 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 21 30.16 2478.13 82.17
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 17 31.50 1748.25 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 446 698.40 52136.31 74.65
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 241 371.82 28046.43 75.43
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 129 175.33 13043.81 74.40
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 219 387.07 21371.35 55.21
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 152 212.32 17649.15 83.13
MED-99202-OUTPATIENT VISIT, NEW, 20 MINS 1 1.00 27.22 27.22
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 3 3.00 555.00 185.00
MED-99204-OUTPATIENT VISIT, NEW, 45 MINS 16 16.00 916.32 57.27
MED-99205-OUTPATIENT VISIT, NEW, 60 MINS 7 7.00 509.46 72.78
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 3 3.00 315.00 105.00
MED-99215-OUTPATIENT VISIT, EST, 40 MINS 3 3.00 150.45 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 77 76.93 3760.61 48.88
VISF-VISF-VISION EVALUATION FUNCTIONAL 1 1.00 70.00 70.00
Subtotal (Total Children Is Unduplicated) 945 2634.16 162646.80 61.75
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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 547 2209.48 155284.56 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 993 3834.63 264300.27 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) 1684 9356.95 611484.93 65.35
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Total 12075.61 777276.73 64.37
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Number of Children (Unduplicated) With at Least One Service 2410
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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 30 24.25 897.25 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
377 366.75 26079.17 0.00
Other 39 56.00 3907.50 0.00
-------------------------------------------------
Total 447 448.00 30933.92 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 24.25 897.25 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
8 376.75 26658.17 0.00
Other 0 56.00 3907.50 0.00
-------------------------------------------------
Total 8 458.00 31512.92 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 24.25 897.25 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
6 395.75 26915.17 0.00
Other 95 151.00 5330.24 0.00
-------------------------------------------------
Total 101 572.00 33192.66 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 20 50.50 3136.50 3967.74
D 0 1.00 50.00 0.00
S 0 24.25 897.25 0.00
H 47 104.48 7036.70 7036.74
T 0 0.00 0.00 0.00
2 397.25 27008.17 0.00
Other 0 151.00 5330.24 0.00
-------------------------------------------------
Total 69 728.48 43458.86 11004.48
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 11 195.75 3518.50 4349.74
D 0 1.00 50.00 0.00
S 0 24.25 897.25 0.00
H 0 104.48 7036.70 7036.74
T 0 0.00 0.00 0.00
1445 1201.00 81190.20 0.00
Other 0 151.00 5330.24 0.00
-------------------------------------------------
Total 1456 1677.48 98022.89 11386.48
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 9 201.75 3925.78 4757.02
D 0 1.00 50.00 0.00
S 0 24.25 897.25 0.00
H 0 104.48 7036.70 7036.74
T 0 0.00 0.00 0.00
2120 2941.25 198651.45 0.00
Other 0 151.00 5330.24 0.00
-------------------------------------------------
Total 2129 3423.73 215891.42 11793.76
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 20 335.00 6894.39 7725.63
D 0 1.00 50.00 0.00
S 0 24.25 897.25 0.00
H 0 104.48 7036.70 7036.74
T 0 0.00 0.00 0.00
120 3157.25 215205.63 0.00
Other 0 151.00 5330.24 0.00
-------------------------------------------------
Total 140 3772.98 235414.21 14762.37
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 4 339.50 7206.97 8234.28
D 0 1.00 50.00 0.00
S 0 24.25 897.25 0.00
H 0 104.48 7036.70 7036.74
T 0 0.00 0.00 0.00
1379 4968.50 338232.01 0.00
Other 0 151.00 5330.24 0.00
-------------------------------------------------
Total 1383 5588.73 358753.17 15271.02
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 0 339.50 7206.97 8234.28
D 0 1.00 50.00 0.00
S 0 24.25 897.25 0.00
H 0 104.48 7036.70 7036.74
T 0 0.00 0.00 0.00
867 6479.75 441697.60 0.00
Other 0 151.00 5330.24 0.00
-------------------------------------------------
Total 867 7099.98 462218.76 15271.02
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 42 454.00 14471.46 15498.77
D 0 1.00 50.00 0.00
S 0 24.25 897.25 0.00
H 0 104.48 7036.70 7036.74
T 0 0.00 0.00 0.00
198 6928.00 471466.51 0.00
Other 0 151.00 5330.24 0.00
-------------------------------------------------
Total 240 7662.73 499252.16 22535.51
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 1 454.89 14531.87 15559.18
D 0 1.00 50.00 0.00
S 0 24.25 897.25 0.00
H 58 196.98 12733.85 7036.74
T 0 0.00 0.00 0.00
578 8245.54 557313.93 173.78
Other 0 151.00 5330.24 0.00
-------------------------------------------------
Total 637 9073.66 590857.14 22769.70
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 6 461.28 14959.69 15987.00
D 0 1.00 50.00 0.00
S 0 24.25 897.25 0.00
H 0 196.98 12733.85 7036.74
T 0 0.00 0.00 0.00
450 8686.70 581795.13 173.78
Other 11 173.00 6824.24 0.00
-------------------------------------------------
Total 467 9543.21 617260.16 23197.52
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 37 503.28 20739.50 18601.07
D 0 1.00 50.00 0.00
S 0 24.25 897.25 0.00
H 0 196.98 12733.85 7036.74
T 0 0.00 0.00 0.00
651 9977.49 656220.18 173.78
Other 0 173.00 6824.24 0.00
-------------------------------------------------
Total 688 10876.00 697465.02 25811.59
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 7 509.28 21168.14 19029.71
D 0 1.00 50.00 0.00
S 0 24.25 897.25 0.00
H 0 196.98 12733.85 7036.74
T 19 15.50 828.64 828.64
858 10602.10 698072.65 173.78
Other 0 173.00 6824.24 0.00
-------------------------------------------------
Total 884 11522.11 740574.77 27068.87
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 0 509.28 21168.14 19029.71
D 0 1.00 50.00 0.00
S 1 25.75 999.07 101.82
H 0 196.98 12733.85 7036.74
T 2 18.00 980.46 980.46
265 11151.60 734520.97 28370.94
Other 0 173.00 6824.24 0.00
-------------------------------------------------
Total 268 12075.61 777276.73 55519.67