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: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 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 18 29.75 1100.75 37.00
Subtotal (Total Children Is Unduplicated) 26 35.00 1258.00 35.94
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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 7 7.00 75.62 10.80
AUDE-92553-PURE TONE AUDIOMETRY AIR & BONE 2 2.00 38.47 19.24
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 107 108.00 957.38 8.86
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 96 99.00 1072.35 10.83
AUDE-92568-ACOUSTIC REFLEX TESTING (MEMR) 4 4.00 33.76 8.44
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 102 104.00 2233.53 21.48
AUDE-92585-AUD EVOKED RESPONSE (DIAG) 3 3.00 163.14 54.38
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 4 4.00 113.12 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-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 51 84.00 6226.00 74.12
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 22 32.50 2437.50 75.00
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 14 21.50 1612.50 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 28 56.33 4237.50 75.23
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 31 52.50 2913.75 55.50
IPDEI-IPDEI_NM-INITIAL PSYCH & DEV EVAL BY NON-MED PR 10 16.72 928.44 55.53
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 508 760.96 56632.15 74.42
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 249 385.79 29033.06 75.26
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 171 237.27 17688.90 74.55
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 230 383.89 21320.17 55.54
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 198 283.89 23492.16 82.75
MED-99202-OUTPATIENT VISIT, NEW, 20 MINS 1 1.00 27.22 27.22
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 5 5.00 925.00 185.00
MED-99204-OUTPATIENT VISIT, NEW, 45 MINS 6 6.00 343.62 57.27
MED-99205-OUTPATIENT VISIT, NEW, 60 MINS 1 1.00 72.78 72.78
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 6 6.00 300.00 50.00
SPCH-92506-SPEECH EVAL BY LICENSED SLP 131 142.17 6904.63 48.57
Subtotal (Total Children Is Unduplicated) 1157 2958.01 186789.57 63.15
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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 663 2739.88 191717.38 69.97
OCCT-97530HM-OT SESSION BY OT ASST 31 62.50 3554.85 56.88
PHY-97110-PT SESSION BY LICENSED PT 598 2411.50 163914.74 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 1300 4838.71 338605.68 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 12 1358.00 841.20 0.62
VISN-T1027SC-EI VISION SERVICES, INDIVIDUAL 1 5.00 250.00 50.00
Subtotal (Total Children Is Unduplicated) 2045 12409.1 740389.68 59.67
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Total 15402.09 928437.25 60.28
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Number of Children (Unduplicated) With at Least One Service 2862
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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 75 101.50 6433.75 0.00
S 1 1.50 55.50 0.00
H 56 67.00 4399.75 0.00
T 0 0.00 0.00 0.00
423 661.70 23308.15 0.00
Other 192 249.50 17237.15 67.88
-------------------------------------------------
Total 747 1081.20 51434.30 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 0 101.50 6433.75 0.00
S 0 1.50 55.50 0.00
H 0 67.00 4399.75 0.00
T 0 0.00 0.00 0.00
12 672.45 23781.90 0.00
Other 0 249.50 17237.15 67.88
-------------------------------------------------
Total 12 1091.95 51908.05 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 0 101.50 6433.75 0.00
S 0 1.50 55.50 0.00
H 0 67.00 4399.75 0.00
T 0 0.00 0.00 0.00
38 725.45 25602.24 0.00
Other 53 302.50 18014.48 67.88
-------------------------------------------------
Total 91 1197.95 54505.72 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 15 14.00 1552.00 3280.28
D 0 101.50 6433.75 0.00
S 0 1.50 55.50 0.00
H 202 468.75 30753.74 26374.35
T 0 0.00 0.00 0.00
0 725.45 25602.24 0.00
Other 0 302.50 18014.48 67.88
-------------------------------------------------
Total 217 1613.70 82411.71 29722.51
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 14.00 1552.00 3280.28
D 0 101.50 6433.75 0.00
S 0 1.50 55.50 0.00
H 0 468.75 30753.74 26374.35
T 0 0.00 0.00 0.00
1092 1350.38 66239.41 0.00
Other 0 302.50 18014.48 67.88
-------------------------------------------------
Total 1092 2238.63 123048.88 29722.51
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 14.00 1552.00 3280.28
D 0 101.50 6433.75 0.00
S 0 1.50 55.50 0.00
H 0 468.75 30753.74 26374.35
T 0 0.00 0.00 0.00
2152 3159.38 190157.84 0.00
Other 0 302.50 18014.48 67.88
-------------------------------------------------
Total 2152 4047.63 246967.31 29722.51
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 45 145.25 9947.21 11675.49
D 0 101.50 6433.75 0.00
S 0 1.50 55.50 0.00
H 0 468.75 30753.74 26374.35
T 0 0.00 0.00 0.00
179 3585.63 219139.93 0.00
Other 0 302.50 18014.48 67.88
-------------------------------------------------
Total 224 4605.13 284344.61 38117.72
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 26 203.25 13905.61 19401.46
D 0 101.50 6433.75 0.00
S 0 1.50 55.50 0.00
H 0 468.75 30753.74 26374.35
T 0 0.00 0.00 0.00
1662 5969.88 383475.21 0.00
Other 0 302.50 18014.48 67.88
-------------------------------------------------
Total 1688 7047.38 452638.29 45843.69
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 2 206.75 14129.11 19624.96
D 0 101.50 6433.75 0.00
S 0 1.50 55.50 0.00
H 0 468.75 30753.74 26374.35
T 0 0.00 0.00 0.00
1612 8628.63 558817.46 0.00
Other 0 302.50 18014.48 67.88
-------------------------------------------------
Total 1614 9709.63 628204.04 46067.19
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 39 602.75 23160.07 28655.92
D 0 101.50 6433.75 0.00
S 0 1.50 55.50 0.00
H 0 468.75 30753.74 26374.35
T 0 0.00 0.00 0.00
207 9048.63 586566.73 0.00
Other 0 302.50 18014.48 67.88
-------------------------------------------------
Total 246 10525.63 664984.27 55098.15
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 0 602.75 23160.07 28655.92
D 0 101.50 6433.75 0.00
S 0 1.50 55.50 0.00
H 73 615.25 39535.68 26374.35
T 0 0.00 0.00 0.00
477 10037.44 650668.01 0.00
Other 0 302.50 18014.48 67.88
-------------------------------------------------
Total 551 11662.94 738003.25 55098.15
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 27 632.53 25029.13 30576.80
D 0 101.50 6433.75 0.00
S 0 1.50 55.50 0.00
H 0 615.25 39535.68 26374.35
T 0 0.00 0.00 0.00
617 10443.48 676653.31 0.00
Other 0 302.50 18014.48 67.88
-------------------------------------------------
Total 644 12098.76 765857.61 57019.03
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 1 633.53 25357.26 30730.56
D 0 101.50 6433.75 0.00
S 0 1.50 55.50 0.00
H 0 615.25 39535.68 26374.35
T 0 0.00 0.00 0.00
613 12171.25 731286.49 0.00
Other 0 302.50 18014.48 67.88
-------------------------------------------------
Total 614 13827.53 820818.92 57172.79
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 8 641.53 25880.92 31254.22
D 0 101.50 6433.75 0.00
S 0 1.50 55.50 0.00
H 16 639.25 43535.68 26374.35
T 0 0.00 0.00 0.00
868 12821.56 774942.41 0.00
Other 0 302.50 18014.48 67.88
-------------------------------------------------
Total 892 14509.84 868998.50 57696.45
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 0 641.53 25880.92 31254.22
D 0 101.50 6433.75 0.00
S 0 1.50 55.50 0.00
H 0 639.25 43535.68 26374.35
T 22 31.50 2093.88 2093.88
454 13682.31 832287.28 54878.19
Other 0 302.50 18014.48 67.88
-------------------------------------------------
Total 476 15402.09 928437.25 114668.52