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: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 6 2.75 101.75 37.00
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 1 1.00 0.00 0.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 1 1.50 55.50 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 15 23.00 851.00 37.00
Subtotal (Total Children Is Unduplicated) 23 28.25 1008.25 35.69
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Screening, Eval, and Assessment,Class #02
ASTE-ASTE-ASSISTIVE TECHNOLOGY EVAL 4 3.09 148.49 48.06
AUDE-92552-PURE TONE AUDIOMETRY -AIR ONLY 6 6.00 63.72 10.62
AUDE-92553-PURE TONE AUDIOMETRY AIR & BONE 2 2.00 38.47 19.24
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 103 104.00 922.04 8.87
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 94 97.00 1050.75 10.83
AUDE-92568-ACOUSTIC REFLEX TESTING (MEMR) 4 4.00 33.76 8.44
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 98 100.00 2166.86 21.67
AUDE-92585-AUD EVOKED RESPONSE (DIAG) 3 3.00 163.14 54.38
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 3 3.00 84.84 28.28
AUDE-92588-OTOACOUSTIC EMISSIONS (COMP) 16 16.00 508.96 31.81
AUDE-V5090-DISPENSING FEE PER HEARING AID 1 2.00 35.65 17.83
EVAL-EVAL-DEVELOPMENTAL EVALUATION 1 4.00 200.00 50.00
EXIT-EXIT-TRANSITION ASSESSMENT 1 0.50 25.00 50.00
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 44 74.00 5476.00 74.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 17 24.50 1837.50 75.00
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 12 19.00 1425.00 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 25 52.00 3900.00 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 22 36.50 2025.75 55.50
IPDEI-IPDEI_NM-INITIAL PSYCH & DEV EVAL BY NON-MED PR 8 14.65 813.34 55.52
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 382 582.84 43428.13 74.51
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 184 292.44 22031.60 75.34
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 120 167.27 12491.90 74.68
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 147 241.82 13435.06 55.56
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 145 217.97 18135.30 83.20
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 5 5.00 286.35 57.27
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 1 1.00 105.00 105.00
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 6 5.61 272.25 48.53
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 73 74.77 3625.47 48.49
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 8 9.00 436.50 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 33 32.52 1538.50 47.31
SCREEN-T1023-INTERDISCIPLINARY SCREENING 3 3.00 150.00 50.00
SPCH-92506-SPEECH EVAL BY LICENSED SLP 131 142.17 6904.63 48.57
Subtotal (Total Children Is Unduplicated) 930 2344.65 144342.18 61.56
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 6 23.00 3730.71 162.20
AUD-HA_FUP-AUDIOLOGY SERVICES 3 3.00 78.53 26.18
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 4 7.00 350.00 50.00
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 2 1.00 50.00 50.00
CONIP-CONIP-CONSULT, ITDS, PHONE 1 0.25 6.25 25.00
CONOF-CONOF-CONSULT, OT, FACE TO FACE 4 3.00 150.00 50.00
CONOP-CONOP-CONSULT, OT, PHONE 1 0.50 12.50 25.00
CONPF-CONPF-CONSULT, PT, FACE TO FACE 1 1.00 50.00 50.00
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 2 2.00 100.00 50.00
EIIF-96154-HEALTH AND BEHAVIOR INTERVENTION 2 25.00 1250.00 50.00
EIIF-EIIF_NM-EI INDIVIDUAL SESSION BY NONMED PROF 6 46.00 2300.00 50.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 100 736.75 24443.63 33.18
HERN-T1027SC-EI HEARING SERVICES AFTER SHINE 1 10.00 500.00 50.00
INTR-INTR-INTERPRETER 1 2.00 88.00 44.00
OCCT-97530-OT SESSION BY LICENSED OT 660 2722.88 190425.78 69.94
OCCT-97530HM-OT SESSION BY OT ASST 31 62.50 3554.85 56.88
PHY-97110-PT SESSION BY LICENSED PT 597 2407.50 163643.22 67.97
PHY-97110HM-PT SESSION BY PT ASST 25 79.49 4567.45 57.46
SENS-HA_EIP-ONE UNIT UP TO $500 PER AID 1 2.00 300.00 150.00
SENS-V5264-EARMOLD 5 7.00 1408.32 201.19
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 1297 4833.21 338232.34 69.98
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 8 31.50 1656.76 52.60
SPL-92508-GROUP SPL SESSION PER CHILD 9 13.00 463.68 35.67
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 10 878.00 505.20 0.58
VISN-T1027SC-EI VISION SERVICES, INDIVIDUAL 1 5.00 250.00 50.00
Subtotal (Total Children Is Unduplicated) 2037 11902.6 738117.22 62.01
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Total 14275.48 883467.65 61.89
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Number of Children (Unduplicated) With at Least One Service 2626
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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 54 70.00 4451.50 0.00
S 1 1.50 55.50 0.00
H 44 55.50 3595.75 0.00
T 0 0.00 0.00 0.00
422 661.20 23276.60 0.00
Other 180 231.50 15887.15 67.88
-------------------------------------------------
Total 701 1019.70 47266.50 67.88
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 70.00 4451.50 0.00
S 0 1.50 55.50 0.00
H 0 55.50 3595.75 0.00
T 0 0.00 0.00 0.00
9 670.95 23713.35 0.00
Other 0 231.50 15887.15 67.88
-------------------------------------------------
Total 9 1029.45 47703.25 67.88
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 70.00 4451.50 0.00
S 0 1.50 55.50 0.00
H 0 55.50 3595.75 0.00
T 0 0.00 0.00 0.00
38 723.95 25533.69 0.00
Other 44 275.50 16522.74 67.88
-------------------------------------------------
Total 82 1126.45 50159.18 67.88
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 11 10.50 1089.00 2314.31
D 0 70.00 4451.50 0.00
S 0 1.50 55.50 0.00
H 198 445.75 29169.12 25593.73
T 0 0.00 0.00 0.00
0 723.95 25533.69 0.00
Other 0 275.50 16522.74 67.88
-------------------------------------------------
Total 209 1527.20 76821.55 27975.92
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 10.50 1089.00 2314.31
D 0 70.00 4451.50 0.00
S 0 1.50 55.50 0.00
H 0 445.75 29169.12 25593.73
T 0 0.00 0.00 0.00
1082 1335.09 65260.10 0.00
Other 0 275.50 16522.74 67.88
-------------------------------------------------
Total 1082 2138.34 116547.96 27975.92
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 10.50 1089.00 2314.31
D 0 70.00 4451.50 0.00
S 0 1.50 55.50 0.00
H 0 445.75 29169.12 25593.73
T 0 0.00 0.00 0.00
2095 3075.59 184002.84 0.00
Other 0 275.50 16522.74 67.88
-------------------------------------------------
Total 2095 3878.84 235290.70 27975.92
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 45 141.75 9484.21 10709.52
D 0 70.00 4451.50 0.00
S 0 1.50 55.50 0.00
H 0 445.75 29169.12 25593.73
T 0 0.00 0.00 0.00
178 3499.84 212834.93 0.00
Other 0 275.50 16522.74 67.88
-------------------------------------------------
Total 223 4434.34 272518.00 36371.13
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 23 196.75 13217.61 18054.49
D 0 70.00 4451.50 0.00
S 0 1.50 55.50 0.00
H 0 445.75 29169.12 25593.73
T 0 0.00 0.00 0.00
1598 5802.09 371156.71 0.00
Other 0 275.50 16522.74 67.88
-------------------------------------------------
Total 1621 6791.59 434573.18 43716.10
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 2 200.25 13441.11 18277.99
D 0 70.00 4451.50 0.00
S 0 1.50 55.50 0.00
H 0 445.75 29169.12 25593.73
T 0 0.00 0.00 0.00
1445 8193.34 528745.41 0.00
Other 0 275.50 16522.74 67.88
-------------------------------------------------
Total 1447 9186.34 592385.38 43939.60
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 39 596.25 22472.07 27308.95
D 0 70.00 4451.50 0.00
S 0 1.50 55.50 0.00
H 0 445.75 29169.12 25593.73
T 0 0.00 0.00 0.00
202 8601.84 555730.20 0.00
Other 0 275.50 16522.74 67.88
-------------------------------------------------
Total 241 9990.84 628401.13 52970.56
Center 52
Flag Claims Units Chgs Paid
-------------------------------------------------
R 0 0.00 0.00 0.00
U 0 0.00 0.00 0.00
B 1 2.00 135.76 0.00
P 0 596.25 22472.07 27308.95
D 0 70.00 4451.50 0.00
S 0 1.50 55.50 0.00
H 64 580.25 37095.56 25593.73
T 0 0.00 0.00 0.00
461 9570.65 618511.23 0.00
Other 0 275.50 16522.74 67.88
-------------------------------------------------
Total 526 11096.15 699244.36 52970.56
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 2.00 135.76 0.00
P 21 618.64 23873.56 28711.27
D 0 70.00 4451.50 0.00
S 0 1.50 55.50 0.00
H 0 580.25 37095.56 25593.73
T 0 0.00 0.00 0.00
614 9972.19 644217.53 0.00
Other 0 275.50 16522.74 67.88
-------------------------------------------------
Total 635 11520.08 726352.15 54372.88
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 2.00 135.76 0.00
P 1 619.64 24201.69 28865.03
D 0 70.00 4451.50 0.00
S 0 1.50 55.50 0.00
H 0 580.25 37095.56 25593.73
T 0 0.00 0.00 0.00
597 11200.50 697235.43 0.00
Other 0 275.50 16522.74 67.88
-------------------------------------------------
Total 598 12749.39 779698.18 54526.64
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 2.00 135.76 0.00
P 8 627.64 24725.35 29388.69
D 0 70.00 4451.50 0.00
S 0 1.50 55.50 0.00
H 13 599.75 40345.56 25593.73
T 0 0.00 0.00 0.00
843 11806.84 737792.49 0.00
Other 0 275.50 16522.74 67.88
-------------------------------------------------
Total 864 13383.23 824028.90 55050.30
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 2.00 135.76 0.00
P 0 627.64 24725.35 29388.69
D 0 70.00 4451.50 0.00
S 0 1.50 55.50 0.00
H 0 599.75 40345.56 25593.73
T 22 31.50 2093.88 2093.88
454 12667.59 795137.36 54878.19
Other 0 275.50 16522.74 67.88
-------------------------------------------------
Total 476 14275.48 883467.65 112022.37