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: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 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 9 7.50 277.50 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 39 103.50 3829.50 37.00
Subtotal (Total Children Is Unduplicated) 48 114.25 4153.25 36.35
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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) 139 139.00 1227.37 8.83
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 128 127.09 1371.76 10.79
AUDE-92568-ACOUSTIC REFLEX TESTING (MEMR) 9 9.00 75.96 8.44
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 146 145.90 3167.75 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 9 17.00 850.00 50.00
EXIT-EXIT-TRANSITION ASSESSMENT 8 15.25 837.50 54.92
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 51 83.00 6198.50 74.68
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 13 21.50 1612.50 75.00
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 12 15.50 1136.00 73.29
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 24 40.50 3290.63 81.25
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 22 37.00 2053.50 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 570 849.20 63343.87 74.59
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 281 427.47 32172.24 75.26
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 159 204.22 15217.15 74.51
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 249 508.32 28333.64 55.74
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 222 306.77 25282.27 82.41
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 12 13.00 962.24 74.02
MED-99205-OUTPATIENT VISIT, NEW, 60 MINS 3 3.00 218.34 72.78
MED-99215-OUTPATIENT VISIT, EST, 40 MINS 3 4.00 200.60 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 41 42.00 2189.73 52.14
SCREEN-T1023-INTERDISCIPLINARY SCREENING 5 5.00 250.00 50.00
SPCH-92506-SPEECH EVAL BY LICENSED SLP 109 114.42 5547.44 48.48
Subtotal (Total Children Is Unduplicated) 1222 3291.01 203206.45 61.75
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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
CONIP-CONIP-CONSULT, ITDS, PHONE 1 0.50 12.50 25.00
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 662 2706.47 187474.05 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) 2001 11517.4 749649.59 65.09
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Total 14922.70 957009.29 64.13
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Number of Children (Unduplicated) With at Least One Service 2916
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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 119 149.50 9242.50 0.00
S 27 35.00 1295.00 0.00
H 21 29.50 1804.99 0.00
T 0 0.00 0.00 0.00
366 296.50 27747.33 11.88
Other 226 485.75 19799.19 0.00
-------------------------------------------------
Total 759 996.25 59889.01 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 0 149.50 9242.50 0.00
S 0 35.00 1295.00 0.00
H 0 29.50 1804.99 0.00
T 0 0.00 0.00 0.00
52 348.25 29795.08 11.88
Other 0 485.75 19799.19 0.00
-------------------------------------------------
Total 52 1048.00 61936.76 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 0 149.50 9242.50 0.00
S 0 35.00 1295.00 0.00
H 0 29.50 1804.99 0.00
T 0 0.00 0.00 0.00
16 409.75 30590.53 11.88
Other 101 586.75 21453.69 0.00
-------------------------------------------------
Total 117 1210.50 64386.71 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 0 149.50 9242.50 0.00
S 0 35.00 1295.00 0.00
H 115 307.10 20330.96 18227.56
T 0 0.00 0.00 0.00
0 409.75 30590.53 11.88
Other 0 586.75 21453.69 0.00
-------------------------------------------------
Total 145 1563.60 87817.97 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 0 149.50 9242.50 0.00
S 0 35.00 1295.00 0.00
H 0 307.10 20330.96 18227.56
T 0 0.00 0.00 0.00
1111 1077.86 72702.18 11.88
Other 0 586.75 21453.69 0.00
-------------------------------------------------
Total 1111 2231.71 129929.62 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 0 149.50 9242.50 0.00
S 0 35.00 1295.00 0.00
H 0 307.10 20330.96 18227.56
T 0 0.00 0.00 0.00
2249 2902.36 195430.39 11.88
Other 0 586.75 21453.69 0.00
-------------------------------------------------
Total 2249 4056.21 252657.83 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 0 149.50 9242.50 0.00
S 0 35.00 1295.00 0.00
H 0 307.10 20330.96 18227.56
T 0 0.00 0.00 0.00
167 3279.11 220378.22 11.88
Other 0 586.75 21453.69 0.00
-------------------------------------------------
Total 198 4504.71 282253.40 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 41 213.50 14059.18 17761.06
D 0 149.50 9242.50 0.00
S 0 35.00 1295.00 0.00
H 0 307.10 20330.96 18227.56
T 0 0.00 0.00 0.00
1730 5620.86 378886.24 397.88
Other 0 586.75 21453.69 0.00
-------------------------------------------------
Total 1771 6912.71 445267.57 36386.50
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 0 213.50 14059.18 17761.06
D 0 149.50 9242.50 0.00
S 0 35.00 1295.00 0.00
H 0 307.10 20330.96 18227.56
T 0 0.00 0.00 0.00
1336 7952.11 536224.78 397.88
Other 0 586.75 21453.69 0.00
-------------------------------------------------
Total 1336 9243.96 602606.11 36386.50
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 34 316.00 20158.37 23860.25
D 0 149.50 9242.50 0.00
S 0 35.00 1295.00 0.00
H 0 307.10 20330.96 18227.56
T 0 0.00 0.00 0.00
248 8461.36 569953.38 397.88
Other 0 586.75 21453.69 0.00
-------------------------------------------------
Total 282 9855.71 642433.90 42485.69
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 0 316.00 20158.37 23860.25
D 0 149.50 9242.50 0.00
S 0 35.00 1295.00 0.00
H 87 463.10 30510.45 18227.56
T 0 0.00 0.00 0.00
664 9720.86 649846.53 397.88
Other 0 586.75 21453.69 0.00
-------------------------------------------------
Total 751 11271.21 732506.54 42485.69
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 29 345.46 22360.82 26062.70
D 0 149.50 9242.50 0.00
S 0 35.00 1295.00 0.00
H 0 463.10 30510.45 18227.56
T 0 0.00 0.00 0.00
557 10176.06 676555.80 397.88
Other 0 586.75 21453.69 0.00
-------------------------------------------------
Total 586 11755.87 761418.26 44688.14
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 25 371.96 26719.58 28362.59
D 0 149.50 9242.50 0.00
S 0 35.00 1295.00 0.00
H 0 463.10 30510.45 18227.56
T 0 0.00 0.00 0.00
694 11592.44 753217.69 397.88
Other 0 586.75 21453.69 0.00
-------------------------------------------------
Total 719 13198.75 842438.91 46988.03
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 18 390.96 28134.14 29777.15
D 0 149.50 9242.50 0.00
S 0 35.00 1295.00 0.00
H 0 463.10 30510.45 18227.56
T 0 0.00 0.00 0.00
1235 12431.89 809472.17 397.88
Other 0 586.75 21453.69 0.00
-------------------------------------------------
Total 1253 14057.20 900107.95 48402.59
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 0 390.96 28134.14 29777.15
D 0 149.50 9242.50 0.00
S 0 35.00 1295.00 0.00
H 0 463.10 30510.45 18227.56
T 3 4.50 305.46 305.46
481 13291.39 865966.23 45077.60
Other 1 588.25 21555.51 101.82
-------------------------------------------------
Total 485 14922.70 957009.29 93489.59