CMS/EIP Fiscal Report Statewide
Services beginning 07/01/2009 ending 09/30/2009 Date of Report:11/17/2009 Page: 1
Payclass Filters:TPIN
Eligibility Filter:Not Part C
List order: No List
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 3 6.75 249.75 37.00
Subtotal (Total Children Is Unduplicated) 3 6.75 249.75 37.00
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Screening, Eval, and Assessment,Class #02
AUDE-92552-PURE TONE AUDIOMETRY -AIR ONLY 1 1.00 11.90 11.90
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 4 4.00 35.34 8.84
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 2 2.00 21.60 10.80
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 4 4.00 66.67 16.67
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 1 1.00 28.28 28.28
IPDEF-IPDEF_NM-F/U PSYCH & DEV EVAL BY NON-MED PROF 1 2.00 111.00 55.50
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 7 10.00 750.00 75.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 5 8.00 600.00 75.00
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 2 2.50 187.50 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 3 4.33 337.50 77.94
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 9 16.00 888.00 55.50
IPDEI-IPDEI_NM-INITIAL PSYCH & DEV EVAL BY NON-MED PR 2 2.07 115.10 55.60
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 123 174.62 12947.47 74.15
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 64 91.85 6888.96 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 51 70.00 5197.00 74.24
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 82 141.07 7829.61 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 50 63.92 5206.86 81.46
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 2 2.00 370.00 185.00
MED-99204-OUTPATIENT VISIT, NEW, 45 MINS 1 1.00 57.27 57.27
SCREEN-T1023-INTERDISCIPLINARY SCREENING 2 2.00 100.00 50.00
Subtotal (Total Children Is Unduplicated) 222 603.36 41750.06 69.20
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EI Services,Class #03
OCCT-97530-OT SESSION BY LICENSED OT 2 8.50 714.62 84.07
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 2 4.50 305.46 67.88
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 2 480.00 336.00 0.70
Subtotal (Total Children Is Unduplicated) 5 493.00 1356.08 2.75
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Total 1103.11 43355.89 39.30
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Number of Children (Unduplicated) With at Least One Service 228
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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 19 29.50 1851.75 0.00
S 0 0.00 0.00 0.00
H 9 10.00 691.50 0.00
T 0 0.00 0.00 0.00
0 0.00 0.00 0.00
Other 11 17.00 1275.00 0.00
-------------------------------------------------
Total 39 56.50 3818.25 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 29.50 1851.75 0.00
S 0 0.00 0.00 0.00
H 0 10.00 691.50 0.00
T 0 0.00 0.00 0.00
3 1.00 37.00 0.00
Other 0 17.00 1275.00 0.00
-------------------------------------------------
Total 3 57.50 3855.25 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 29.50 1851.75 0.00
S 0 0.00 0.00 0.00
H 0 10.00 691.50 0.00
T 0 0.00 0.00 0.00
0 1.00 37.00 0.00
Other 9 26.00 1416.74 0.00
-------------------------------------------------
Total 9 66.50 3996.99 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 4 3.50 463.00 965.97
D 0 29.50 1851.75 0.00
S 0 0.00 0.00 0.00
H 4 21.50 1472.12 780.62
T 0 0.00 0.00 0.00
0 1.00 37.00 0.00
Other 0 26.00 1416.74 0.00
-------------------------------------------------
Total 8 81.50 5240.61 1746.59
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 3.50 463.00 965.97
D 0 29.50 1851.75 0.00
S 0 0.00 0.00 0.00
H 0 21.50 1472.12 780.62
T 0 0.00 0.00 0.00
8 12.79 824.98 0.00
Other 0 26.00 1416.74 0.00
-------------------------------------------------
Total 8 93.29 6028.59 1746.59
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 3.50 463.00 965.97
D 0 29.50 1851.75 0.00
S 0 0.00 0.00 0.00
H 0 21.50 1472.12 780.62
T 0 0.00 0.00 0.00
49 73.29 5436.27 0.00
Other 0 26.00 1416.74 0.00
-------------------------------------------------
Total 49 153.79 10639.88 1746.59
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 3.50 463.00 965.97
D 0 29.50 1851.75 0.00
S 0 0.00 0.00 0.00
H 0 21.50 1472.12 780.62
T 0 0.00 0.00 0.00
1 75.29 5586.27 0.00
Other 0 26.00 1416.74 0.00
-------------------------------------------------
Total 1 155.79 10789.88 1746.59
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 3 6.50 688.00 1346.97
D 0 29.50 1851.75 0.00
S 0 0.00 0.00 0.00
H 0 21.50 1472.12 780.62
T 0 0.00 0.00 0.00
64 157.29 11599.77 0.00
Other 0 26.00 1416.74 0.00
-------------------------------------------------
Total 67 240.79 17028.38 2127.59
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 6.50 688.00 1346.97
D 0 29.50 1851.75 0.00
S 0 0.00 0.00 0.00
H 0 21.50 1472.12 780.62
T 0 0.00 0.00 0.00
167 424.79 29353.32 0.00
Other 0 26.00 1416.74 0.00
-------------------------------------------------
Total 167 508.29 34781.93 2127.59
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 6.50 688.00 1346.97
D 0 29.50 1851.75 0.00
S 0 0.00 0.00 0.00
H 0 21.50 1472.12 780.62
T 0 0.00 0.00 0.00
2 427.79 29540.82 0.00
Other 0 26.00 1416.74 0.00
-------------------------------------------------
Total 2 511.29 34969.43 2127.59
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 6.50 688.00 1346.97
D 0 29.50 1851.75 0.00
S 0 0.00 0.00 0.00
H 9 33.50 2327.62 780.62
T 0 0.00 0.00 0.00
16 447.79 30861.07 0.00
Other 0 26.00 1416.74 0.00
-------------------------------------------------
Total 25 543.29 37145.18 2127.59
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 13.89 1155.57 1865.53
D 0 29.50 1851.75 0.00
S 0 0.00 0.00 0.00
H 0 33.50 2327.62 780.62
T 0 0.00 0.00 0.00
3 452.29 31140.07 0.00
Other 0 26.00 1416.74 0.00
-------------------------------------------------
Total 9 555.18 37891.75 2646.15
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 0 13.89 1155.57 1865.53
D 0 29.50 1851.75 0.00
S 0 0.00 0.00 0.00
H 0 33.50 2327.62 780.62
T 0 0.00 0.00 0.00
16 951.75 32755.35 0.00
Other 0 26.00 1416.74 0.00
-------------------------------------------------
Total 16 1054.64 39507.03 2646.15
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 13.89 1155.57 1865.53
D 0 29.50 1851.75 0.00
S 0 0.00 0.00 0.00
H 3 38.00 3077.62 780.62
T 0 0.00 0.00 0.00
25 995.72 35854.21 0.00
Other 0 26.00 1416.74 0.00
-------------------------------------------------
Total 28 1103.11 43355.89 2646.15