CMS/EIP Fiscal Report Statewide
Services beginning 04/01/2009 ending 06/30/2009 Date of Report:08/25/2009 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 5 1.25 46.25 37.00
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 2 2.00 0.00 0.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 7 5.50 203.50 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 37 94.00 3478.00 37.00
Subtotal (Total Children Is Unduplicated) 45 102.75 3727.75 36.28
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Screening, Eval, and Assessment,Class #02
ASTE-ASTE-ASSISTIVE TECHNOLOGY EVAL 1 1.00 48.50 48.50
AUDE-92552-PURE TONE AUDIOMETRY -AIR ONLY 9 9.00 95.58 10.62
AUDE-92553-PURE TONE AUDIOMETRY AIR & BONE 3 3.00 48.90 16.30
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 132 132.00 1165.56 8.83
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 123 122.09 1317.76 10.79
AUDE-92568-ACOUSTIC REFLEX TESTING (MEMR) 9 9.00 75.96 8.44
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 139 138.90 3015.22 21.71
AUDE-92585-AUD EVOKED RESPONSE (DIAG) 9 9.00 489.42 54.38
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 17 17.00 462.86 27.23
AUDE-92588-OTOACOUSTIC EMISSIONS (COMP) 21 21.00 668.01 31.81
AUDE-92682-CONDITIONED PLAY AUDIOMETRY 1 1.00 21.34 21.34
AUDE-V5090-DISPENSING FEE PER HEARING AID 1 2.00 239.20 119.60
BEHV-H0031HO-COMP BEHAVIORAL HEALTH ASSESSMENT 1 1.00 125.00 125.00
EVAL-EVAL-DEVELOPMENTAL EVALUATION 7 15.00 750.00 50.00
EXIT-EXIT-TRANSITION ASSESSMENT 8 15.25 837.50 54.92
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 43 73.50 5512.50 75.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 10 16.50 1237.50 75.00
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 9 12.50 937.50 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 23 39.50 3215.63 81.41
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 18 30.50 1692.75 55.50
IPDEI-IPDEI_NM-INITIAL PSYCH & DEV EVAL BY NON-MED PR 4 4.85 268.75 55.41
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 419 635.54 47319.38 74.46
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 222 342.37 25789.82 75.33
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 111 145.72 10882.65 74.68
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 159 359.74 20087.39 55.84
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 156 219.77 17860.38 81.27
MED-99202-OUTPATIENT VISIT, NEW, 20 MINS 4 4.00 108.88 27.22
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 5 5.00 925.00 185.00
MED-99204-OUTPATIENT VISIT, NEW, 45 MINS 11 12.00 904.97 75.41
MED-99205-OUTPATIENT VISIT, NEW, 60 MINS 2 2.00 145.56 72.78
MED-99215-OUTPATIENT VISIT, EST, 40 MINS 2 3.00 150.45 50.15
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 10 8.08 433.63 53.67
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 61 60.01 2911.10 48.51
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 15 16.93 821.29 48.51
PSTH-97001-EVAL BY LICENSED PT, INITIAL 40 41.00 2141.23 52.23
SCREEN-T1023-INTERDISCIPLINARY SCREENING 3 3.00 150.00 50.00
SPCH-92506-SPEECH EVAL BY LICENSED SLP 109 114.42 5547.44 48.48
Subtotal (Total Children Is Unduplicated) 978 2646.17 158404.61 59.86
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 7 10.00 4563.44 456.34
AUD-HA_FUP-AUDIOLOGY SERVICES 2 2.00 100.00 50.00
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 10 13.00 650.00 50.00
COIFP-COIFP-IFSP CONSULT, PRO, BY PHONE 1 1.00 25.00 25.00
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 1 0.50 25.00 50.00
CONOF-CONOF-CONSULT, OT, FACE TO FACE 4 2.75 137.50 50.00
CONPF-CONPF-CONSULT, PT, FACE TO FACE 5 2.50 125.00 50.00
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 3 2.50 125.00 50.00
COUN-H2019HR-INDIVIDUAL/FAMILY THERAPY 1 1.50 105.00 70.00
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 2 5.00 125.00 25.00
EIIF-96154-HEALTH AND BEHAVIOR INTERVENTION 4 20.25 1012.50 50.00
EIIF-EIIF_NM-EI INDIVIDUAL SESSION BY NONMED PROF 1 1.00 50.00 50.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 126 569.84 28894.64 50.71
HERN-T1027SC-EI HEARING SERVICES AFTER SHINE 1 7.75 387.50 50.00
OCCT-97530-OT SESSION BY LICENSED OT 660 2699.47 186998.89 69.27
OCCT-97530HM-OT SESSION BY OT ASST 31 128.25 6993.66 54.53
PHY-97110-PT SESSION BY LICENSED PT 608 2491.02 171894.83 69.01
PHY-97110HM-PT SESSION BY PT ASST 23 84.96 4882.78 57.47
SENS-HA_EIP-ONE UNIT UP TO $500 PER AID 1 2.00 1000.00 500.00
SENS-V5264-EARMOLD 5 10.00 187.20 18.72
SHIN-T1027SC-INITIAL SHINE SERVICES, INDIVIDUAL 1 1.50 75.00 50.00
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 1230 4864.90 338807.21 69.64
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 4 6.00 325.92 54.32
SPL-92508-GROUP SPL SESSION PER CHILD 26 51.25 951.61 18.57
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 12 523.00 319.25 0.61
VISN-EIIF_NM-EI VISION SERVICES, IND NONMED 1 8.00 400.00 50.00
Subtotal (Total Children Is Unduplicated) 1998 11509.9 749161.93 65.09
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Total 14258.86 911294.29 63.91
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Number of Children (Unduplicated) With at Least One Service 2666
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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 93 121.00 7290.25 0.00
S 19 24.75 915.75 0.00
H 12 19.50 1152.49 0.00
T 0 0.00 0.00 0.00
364 294.25 27626.08 11.88
Other 215 470.25 18714.69 0.00
-------------------------------------------------
Total 703 929.75 55699.26 11.88
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 0 121.00 7290.25 0.00
S 0 24.75 915.75 0.00
H 0 19.50 1152.49 0.00
T 0 0.00 0.00 0.00
52 346.00 29673.83 11.88
Other 0 470.25 18714.69 0.00
-------------------------------------------------
Total 52 981.50 57747.01 11.88
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 0 121.00 7290.25 0.00
S 0 24.75 915.75 0.00
H 0 19.50 1152.49 0.00
T 0 0.00 0.00 0.00
16 407.50 30469.28 11.88
Other 91 561.25 20225.11 0.00
-------------------------------------------------
Total 107 1134.00 60052.88 11.88
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 30 75.50 4905.29 6237.39
D 0 121.00 7290.25 0.00
S 0 24.75 915.75 0.00
H 115 297.10 19678.46 18227.56
T 0 0.00 0.00 0.00
0 407.50 30469.28 11.88
Other 0 561.25 20225.11 0.00
-------------------------------------------------
Total 145 1487.10 83484.14 24476.83
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 75.50 4905.29 6237.39
D 0 121.00 7290.25 0.00
S 0 24.75 915.75 0.00
H 0 297.10 19678.46 18227.56
T 0 0.00 0.00 0.00
1105 1069.61 72208.00 11.88
Other 0 561.25 20225.11 0.00
-------------------------------------------------
Total 1105 2149.21 125222.86 24476.83
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 75.50 4905.29 6237.39
D 0 121.00 7290.25 0.00
S 0 24.75 915.75 0.00
H 0 297.10 19678.46 18227.56
T 0 0.00 0.00 0.00
2184 2813.61 189495.66 11.88
Other 0 561.25 20225.11 0.00
-------------------------------------------------
Total 2184 3893.21 242510.52 24476.83
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 31 147.25 9553.03 10885.13
D 0 121.00 7290.25 0.00
S 0 24.75 915.75 0.00
H 0 297.10 19678.46 18227.56
T 0 0.00 0.00 0.00
165 3187.36 214218.49 11.88
Other 0 561.25 20225.11 0.00
-------------------------------------------------
Total 196 4338.71 271881.09 29124.57
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 40 212.50 13984.18 17681.06
D 0 121.00 7290.25 0.00
S 0 24.75 915.75 0.00
H 0 297.10 19678.46 18227.56
T 0 0.00 0.00 0.00
1664 5459.61 367631.01 397.88
Other 0 561.25 20225.11 0.00
-------------------------------------------------
Total 1704 6676.21 429724.76 36306.50
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 0 212.50 13984.18 17681.06
D 0 121.00 7290.25 0.00
S 0 24.75 915.75 0.00
H 0 297.10 19678.46 18227.56
T 0 0.00 0.00 0.00
1166 7503.36 505483.80 397.88
Other 0 561.25 20225.11 0.00
-------------------------------------------------
Total 1166 8719.96 567577.55 36306.50
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 34 315.00 20083.37 23780.25
D 0 121.00 7290.25 0.00
S 0 24.75 915.75 0.00
H 0 297.10 19678.46 18227.56
T 0 0.00 0.00 0.00
246 8008.11 538896.26 397.88
Other 0 561.25 20225.11 0.00
-------------------------------------------------
Total 280 9327.21 607089.20 42405.69
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 0 315.00 20083.37 23780.25
D 0 121.00 7290.25 0.00
S 0 24.75 915.75 0.00
H 78 440.60 28939.95 18227.56
T 0 0.00 0.00 0.00
632 9224.11 615975.41 397.88
Other 0 561.25 20225.11 0.00
-------------------------------------------------
Total 710 10686.71 693429.84 42405.69
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 26 341.78 22105.82 25802.70
D 0 121.00 7290.25 0.00
S 0 24.75 915.75 0.00
H 0 440.60 28939.95 18227.56
T 0 0.00 0.00 0.00
555 9675.31 642423.68 397.88
Other 0 561.25 20225.11 0.00
-------------------------------------------------
Total 581 11164.69 721900.56 44428.14
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 22 364.78 25480.19 27571.50
D 0 121.00 7290.25 0.00
S 0 24.75 915.75 0.00
H 0 440.60 28939.95 18227.56
T 0 0.00 0.00 0.00
668 11060.19 716767.57 397.88
Other 0 561.25 20225.11 0.00
-------------------------------------------------
Total 690 12572.57 799618.82 46196.94
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 16 380.78 26494.75 28586.06
D 0 121.00 7290.25 0.00
S 0 24.75 915.75 0.00
H 0 440.60 28939.95 18227.56
T 0 0.00 0.00 0.00
1214 11864.98 770527.14 397.88
Other 0 561.25 20225.11 0.00
-------------------------------------------------
Total 1230 13393.36 854392.95 47211.50
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 0 380.78 26494.75 28586.06
D 0 121.00 7290.25 0.00
S 0 24.75 915.75 0.00
H 0 440.60 28939.95 18227.56
T 3 4.50 305.46 305.46
481 12724.48 827021.20 45077.60
Other 1 562.75 20326.93 101.82
-------------------------------------------------
Total 485 14258.86 911294.29 92298.50