CMS/EIP Fiscal Report Statewide
Services beginning 04/01/2009 ending 06/30/2009 Date of Report:08/25/2009 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 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
AUDE-92552-PURE TONE AUDIOMETRY -AIR ONLY 1 1.00 10.62 10.62
AUDE-92553-PURE TONE AUDIOMETRY AIR & BONE 3 3.00 48.90 16.30
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 99 99.00 874.17 8.83
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 80 80.00 864.00 10.80
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 95 95.00 2070.05 21.79
AUDE-92585-AUD EVOKED RESPONSE (DIAG) 3 3.00 163.14 54.38
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 9 9.00 254.52 28.28
EVAL-EVAL-DEVELOPMENTAL EVALUATION 5 9.50 475.00 50.00
EXIT-EXIT-TRANSITION ASSESSMENT 5 11.25 575.00 51.11
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 37 65.00 4875.00 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 7 9.50 712.50 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 17 29.50 1637.25 55.50
IPDEI-IPDEI_NM-INITIAL PSYCH & DEV EVAL BY NON-MED PR 2 2.35 130.00 55.32
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 314 486.03 36451.79 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 200 309.06 23290.57 75.36
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 63 83.23 6242.50 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 144 235.74 13205.39 56.02
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 146 208.40 17035.90 81.75
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
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 2 2.00 97.00 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 1 1.00 48.50 48.50
SCREEN-T1023-INTERDISCIPLINARY SCREENING 3 3.00 150.00 50.00
SPCH-92506-SPEECH EVAL BY LICENSED SLP 19 19.00 921.50 48.50
Subtotal (Total Children Is Unduplicated) 621 1846.56 116821.29 63.26
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 5 8.00 400.00 50.00
COIFP-COIFP-IFSP CONSULT, PRO, BY PHONE 1 1.00 25.00 25.00
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 2 5.00 125.00 25.00
EIIF-96154-HEALTH AND BEHAVIOR INTERVENTION 2 12.50 625.00 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 62 270.00 13852.46 51.31
OCCT-97530-OT SESSION BY LICENSED OT 31 175.25 11895.97 67.88
PHY-97110-PT SESSION BY LICENSED PT 12 49.50 3360.06 67.88
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 50 233.75 15866.95 67.88
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 4 44.00 27.25 0.62
Subtotal (Total Children Is Unduplicated) 155 800.00 46227.69 57.78
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Total 2749.31 166776.73 60.66
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Number of Children (Unduplicated) With at Least One Service 795
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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
9 8.50 327.50 0.00
Other 0 0.00 0.00 0.00
-------------------------------------------------
Total 133 173.75 9685.99 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 0 121.00 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
49 54.75 2001.75 0.00
Other 0 0.00 0.00 0.00
-------------------------------------------------
Total 49 220.00 11360.24 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 0 121.00 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
1 55.25 2020.25 0.00
Other 91 91.00 1510.42 0.00
-------------------------------------------------
Total 92 311.50 12889.16 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 11 11.50 1563.75 2895.85
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
0 55.25 2020.25 0.00
Other 0 91.00 1510.42 0.00
-------------------------------------------------
Total 11 323.00 14452.91 2895.85
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 11.50 1563.75 2895.85
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
6 59.75 2284.31 0.00
Other 0 91.00 1510.42 0.00
-------------------------------------------------
Total 6 327.50 14716.97 2895.85
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 11.50 1563.75 2895.85
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
519 734.75 40408.60 0.00
Other 0 91.00 1510.42 0.00
-------------------------------------------------
Total 519 1002.50 52841.26 2895.85
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 11.50 1563.75 2895.85
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
1 736.75 40558.60 0.00
Other 0 91.00 1510.42 0.00
-------------------------------------------------
Total 1 1004.50 52991.26 2895.85
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 11.50 1563.75 2895.85
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
423 1245.25 74315.52 0.00
Other 0 91.00 1510.42 0.00
-------------------------------------------------
Total 423 1513.00 86748.18 2895.85
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 11.50 1563.75 2895.85
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
269 1727.25 107852.52 0.00
Other 0 91.00 1510.42 0.00
-------------------------------------------------
Total 269 1995.00 120285.18 2895.85
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 11.50 1563.75 2895.85
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
7 1734.25 108315.42 0.00
Other 0 91.00 1510.42 0.00
-------------------------------------------------
Total 7 2002.00 120748.08 2895.85
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 11.50 1563.75 2895.85
D 0 121.00 7290.25 0.00
S 0 24.75 915.75 0.00
H 78 163.00 10413.98 0.00
T 0 0.00 0.00 0.00
181 2075.75 129214.59 0.00
Other 0 91.00 1510.42 0.00
-------------------------------------------------
Total 259 2487.00 150908.74 2895.85
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 38.28 3586.20 4918.30
D 0 121.00 7290.25 0.00
S 0 24.75 915.75 0.00
H 0 163.00 10413.98 0.00
T 0 0.00 0.00 0.00
45 2127.75 131886.59 0.00
Other 0 91.00 1510.42 0.00
-------------------------------------------------
Total 71 2565.78 155603.19 4918.30
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 22 61.28 6960.57 6687.10
D 0 121.00 7290.25 0.00
S 0 24.75 915.75 0.00
H 0 163.00 10413.98 0.00
T 0 0.00 0.00 0.00
119 2262.00 138349.59 0.00
Other 0 91.00 1510.42 0.00
-------------------------------------------------
Total 141 2723.03 165440.56 6687.10
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 61.28 6960.57 6687.10
D 0 121.00 7290.25 0.00
S 0 24.75 915.75 0.00
H 0 163.00 10413.98 0.00
T 0 0.00 0.00 0.00
20 2288.28 139685.76 0.00
Other 0 91.00 1510.42 0.00
-------------------------------------------------
Total 20 2749.31 166776.73 6687.10