CMS/EIP Fiscal Report Statewide
Services beginning 07/01/2009 ending 09/30/2009 Date of Report:11/17/2009 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 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 2 1.09 52.99 48.61
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 76 76.00 671.08 8.83
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 61 61.00 658.80 10.80
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 73 73.00 1590.67 21.79
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 41 68.50 5063.50 73.92
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 15 20.50 1537.50 75.00
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 10 15.00 1125.00 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 18 30.00 1665.00 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 291 436.64 32748.27 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 148 233.00 17728.13 76.09
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 76 99.77 7482.40 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 136 222.82 12386.06 55.59
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 143 216.04 17990.43 83.27
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
OCTH-97003-OT EVAL BY LICENSED OT, 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 4 4.00 194.00 48.50
Subtotal (Total Children Is Unduplicated) 578 1638.01 106779.24 65.19
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 4 7.00 350.00 50.00
EIIF-96154-HEALTH AND BEHAVIOR INTERVENTION 1 4.00 200.00 50.00
EIIF-EIIF_NM-EI INDIVIDUAL SESSION BY NONMED PROF 1 14.00 700.00 50.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 43 230.75 11537.50 50.00
OCCT-97530-OT SESSION BY LICENSED OT 25 101.25 6872.85 67.88
PHY-97110-PT SESSION BY LICENSED PT 10 38.50 2613.38 67.88
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 46 154.75 10504.43 67.88
Subtotal (Total Children Is Unduplicated) 123 550.25 32778.16 59.57
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Total 2216.51 140565.65 63.42
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Number of Children (Unduplicated) With at Least One Service 709
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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 53 69.00 4401.50 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
9 2.75 101.75 0.00
Other 19 25.00 1855.50 0.00
-------------------------------------------------
Total 126 153.75 10010.00 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 69.00 4401.50 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
8 10.50 388.50 0.00
Other 0 25.00 1855.50 0.00
-------------------------------------------------
Total 8 161.50 10296.75 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 69.00 4401.50 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
0 10.50 388.50 0.00
Other 44 69.00 2491.09 0.00
-------------------------------------------------
Total 44 205.50 10932.34 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 10.50 1089.00 2314.31
D 0 69.00 4401.50 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
0 10.50 388.50 0.00
Other 0 69.00 2491.09 0.00
-------------------------------------------------
Total 11 216.00 12021.34 2314.31
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 69.00 4401.50 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
408 528.50 28937.03 0.00
Other 0 69.00 2491.09 0.00
-------------------------------------------------
Total 408 734.00 40569.87 2314.31
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 10.50 1089.00 2314.31
D 0 69.00 4401.50 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
2 529.25 28971.28 0.00
Other 0 69.00 2491.09 0.00
-------------------------------------------------
Total 2 734.75 40604.12 2314.31
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 10.50 1089.00 2314.31
D 0 69.00 4401.50 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
378 1031.00 64797.22 0.00
Other 0 69.00 2491.09 0.00
-------------------------------------------------
Total 378 1236.50 76430.06 2314.31
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 14.00 1312.50 2537.81
D 0 69.00 4401.50 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
207 1403.00 90483.97 0.00
Other 0 69.00 2491.09 0.00
-------------------------------------------------
Total 209 1612.00 102340.31 2537.81
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 14.00 1312.50 2537.81
D 0 69.00 4401.50 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
17 1420.00 91618.55 0.00
Other 0 69.00 2491.09 0.00
-------------------------------------------------
Total 17 1629.00 103474.89 2537.81
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 14.00 1312.50 2537.81
D 0 69.00 4401.50 0.00
S 0 1.50 55.50 0.00
H 64 190.00 11522.19 0.00
T 0 0.00 0.00 0.00
96 1606.75 103614.00 0.00
Other 0 69.00 2491.09 0.00
-------------------------------------------------
Total 161 1952.25 123532.54 2537.81
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 19 35.51 2653.99 3880.13
D 0 69.00 4401.50 0.00
S 0 1.50 55.50 0.00
H 0 190.00 11522.19 0.00
T 0 0.00 0.00 0.00
30 1654.75 106446.00 0.00
Other 0 69.00 2491.09 0.00
-------------------------------------------------
Total 49 2021.76 127706.03 3880.13
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 36.51 2982.12 4033.89
D 0 69.00 4401.50 0.00
S 0 1.50 55.50 0.00
H 0 190.00 11522.19 0.00
T 0 0.00 0.00 0.00
161 1821.25 115212.74 0.00
Other 0 69.00 2491.09 0.00
-------------------------------------------------
Total 162 2189.26 136800.90 4033.89
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 0 36.51 2982.12 4033.89
D 0 69.00 4401.50 0.00
S 0 1.50 55.50 0.00
H 13 209.50 14772.19 0.00
T 0 0.00 0.00 0.00
7 1829.00 115727.49 0.00
Other 0 69.00 2491.09 0.00
-------------------------------------------------
Total 20 2216.51 140565.65 4033.89