CMS/EIP Fiscal Report Statewide
Services beginning 10/01/2009 ending 12/31/2009 Date of Report:02/16/2010 Page: 1
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
CASE-CASE-NON-TCM CASE MANAGEMENT 443 218.50 8084.50 37.00
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 203 210.00 0.00 0.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 720 815.00 30155.00 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 1674 6118.25 226164.50 36.97
TCON-TCON-TRANSITION CONFERENCE 3 77.00 0.00 0.00
Subtotal (Total Children Is Unduplicated) 1709 7438.75 264404.00 35.54
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Screening, Eval, and Assessment,Class #02
AUDE-92552-PURE TONE AUDIOMETRY -AIR ONLY 5 5.00 53.10 10.62
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 9 9.00 79.47 8.83
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 8 8.00 84.30 10.54
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 9 9.00 196.11 21.79
AUDE-92585-AUD EVOKED RESPONSE (DIAG) 1 1.00 54.38 54.38
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 4 4.00 113.12 28.28
EVAL-EVAL-DEVELOPMENTAL EVALUATION 4 4.50 225.00 50.00
IPDEF-IPDEF_NM-F/U PSYCH & DEV EVAL BY NON-MED PROF 3 6.00 333.00 55.50
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 29 43.50 3262.50 75.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 16 25.50 1912.50 75.00
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 10 14.50 1087.50 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 14 21.50 1612.50 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 29 43.00 2386.50 55.50
IPDEI-IPDEI_NM-INITIAL PSYCH & DEV EVAL BY NON-MED PR 21 35.00 2058.82 58.82
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 485 653.74 48191.24 73.72
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 249 381.50 28370.50 74.37
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 176 237.00 17775.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 594 911.00 50658.32 55.61
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 329 469.00 35303.57 75.27
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 31 31.00 5735.00 185.00
SCREEN-T1023-INTERDISCIPLINARY SCREENING 35 36.00 1800.00 50.00
SPCH-92506-SPEECH EVAL BY LICENSED SLP 5 5.00 242.50 48.50
Subtotal (Total Children Is Unduplicated) 1038 2953.74 201534.93 68.23
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EI Services,Class #03
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 1 1.00 50.00 50.00
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 1 1.00 50.00 50.00
EIIF-EIIF_NM-EI INDIVIDUAL SESSION BY NONMED PROF 1 4.00 200.00 50.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 4 6.25 312.50 50.00
INTR-INTR-INTERPRETER 17 27.75 1175.00 42.34
OCCT-97530-OT SESSION BY LICENSED OT 1 1.50 101.82 67.88
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 2 6.00 407.28 67.88
TRAN-TRAN-FAMILY TRANSPORTATION 72 73.00 584.00 8.00
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 276 18264.0 10342.45 0.57
Subtotal (Total Children Is Unduplicated) 364 18384.5 13223.05 0.72
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Total 28776.99 479161.98 16.65
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Number of Children (Unduplicated) With at Least One Service 1755
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Center 01
Flag Claims Units Chgs Paid
-------------------------------------------------
R 10 11.00 545.75 0.00
U 0 0.00 0.00 0.00
B 230 205.00 7838.75 0.00
P 16 301.75 701.00 608.50
D 36 65.00 4603.50 0.00
S 183 153.25 5670.25 0.00
H 2 3.50 262.50 0.00
T 4 69.50 108.50 108.50
625 459.50 17755.50 0.00
Other 11 140.50 953.00 0.00
-------------------------------------------------
Total 1117 1409.00 38438.75 717.00
Center 02
Flag Claims Units Chgs Paid
-------------------------------------------------
R 0 11.00 545.75 0.00
U 0 0.00 0.00 0.00
B 67 271.50 10243.75 0.00
P 0 301.75 701.00 608.50
D 0 65.00 4603.50 0.00
S 0 153.25 5670.25 0.00
H 0 3.50 262.50 0.00
T 27 1213.00 1505.75 1505.75
124 1319.00 24243.75 0.00
Other 0 140.50 953.00 0.00
-------------------------------------------------
Total 218 3478.50 48729.25 2114.25
Center 03
Flag Claims Units Chgs Paid
-------------------------------------------------
R 4 16.00 730.75 0.00
U 0 0.00 0.00 0.00
B 9 281.25 10604.50 0.00
P 281 560.00 10783.75 10694.25
D 0 65.00 4603.50 0.00
S 0 153.25 5670.25 0.00
H 0 3.50 262.50 0.00
T 309 1469.25 13202.00 13202.00
149 1475.50 31675.25 0.00
Other 7 147.50 1107.70 0.00
-------------------------------------------------
Total 759 4171.25 78640.20 23896.25
Center 04
Flag Claims Units Chgs Paid
-------------------------------------------------
R 16 30.00 1475.25 0.00
U 0 0.00 0.00 0.00
B 174 509.75 20776.00 0.00
P 108 733.50 17241.25 17142.93
D 0 65.00 4603.50 0.00
S 0 153.25 5670.25 0.00
H 0 3.50 262.50 0.00
T 0 1469.25 13202.00 13202.00
601 2086.50 55526.00 0.00
Other 0 147.50 1107.70 0.00
-------------------------------------------------
Total 899 5198.25 119864.45 30344.93
Center 05
Flag Claims Units Chgs Paid
-------------------------------------------------
R 16 43.75 1984.00 0.00
U 0 0.00 0.00 0.00
B 28 528.50 21469.75 0.00
P 10 926.00 17993.00 17894.68
D 0 65.00 4603.50 0.00
S 0 153.25 5670.25 0.00
H 0 3.50 262.50 0.00
T 0 1469.25 13202.00 13202.00
302 2612.70 63075.25 0.00
Other 0 147.50 1107.70 0.00
-------------------------------------------------
Total 356 5949.45 129367.95 31096.68
Center 06
Flag Claims Units Chgs Paid
-------------------------------------------------
R 0 43.75 1984.00 0.00
U 0 0.00 0.00 0.00
B 12 535.50 21728.75 0.00
P 163 1054.25 22900.25 22801.93
D 0 65.00 4603.50 0.00
S 0 153.25 5670.25 0.00
H 0 3.50 262.50 0.00
T 0 1469.25 13202.00 13202.00
468 3255.95 81949.48 225.00
Other 0 147.50 1107.70 0.00
-------------------------------------------------
Total 643 6727.95 153408.43 36228.93
Center 07
Flag Claims Units Chgs Paid
-------------------------------------------------
R 12 52.75 2317.00 0.00
U 0 0.00 0.00 0.00
B 254 760.75 31229.25 0.00
P 56 2037.75 26460.49 26362.17
D 0 65.00 4603.50 0.00
S 0 153.25 5670.25 0.00
H 0 3.50 262.50 0.00
T 0 1469.25 13202.00 13202.00
626 4352.95 101935.98 225.00
Other 0 147.50 1107.70 0.00
-------------------------------------------------
Total 948 9042.70 186788.67 39789.17
Center 09
Flag Claims Units Chgs Paid
-------------------------------------------------
R 10 68.00 3014.25 0.00
U 0 0.00 0.00 0.00
B 205 1010.75 45020.75 0.00
P 233 2737.25 39504.74 39406.42
D 0 65.00 4603.50 0.00
S 0 153.25 5670.25 0.00
H 0 3.50 262.50 0.00
T 148 1695.25 19092.00 19092.00
150 4533.70 113148.73 225.00
Other 0 147.50 1107.70 0.00
-------------------------------------------------
Total 746 10414.20 231424.42 58723.42
Center 10
Flag Claims Units Chgs Paid
-------------------------------------------------
R 74 145.00 6762.00 0.00
U 0 0.00 0.00 0.00
B 789 1732.00 75711.50 0.00
P 222 3044.75 57518.93 57420.61
D 0 65.00 4603.50 0.00
S 7 157.50 5827.50 0.00
H 0 3.50 262.50 0.00
T 0 1695.25 19092.00 19092.00
1139 5736.70 170546.73 225.00
Other 0 147.50 1107.70 0.00
-------------------------------------------------
Total 2231 12727.20 341432.36 76737.61
Center 51
Flag Claims Units Chgs Paid
-------------------------------------------------
R 3 149.00 7005.00 0.00
U 0 0.00 0.00 0.00
B 199 1917.00 82784.50 0.00
P 84 5079.75 60716.57 60618.25
D 0 65.00 4603.50 0.00
S 0 157.50 5827.50 0.00
H 0 3.50 262.50 0.00
T 0 1695.25 19092.00 19092.00
264 5979.20 181147.23 225.00
Other 0 147.50 1107.70 0.00
-------------------------------------------------
Total 550 15193.70 362546.50 79935.25
Center 52
Flag Claims Units Chgs Paid
-------------------------------------------------
R 0 149.00 7005.00 0.00
U 0 0.00 0.00 0.00
B 67 1980.75 85623.00 0.00
P 106 5209.25 64387.82 64289.50
D 0 65.00 4603.50 0.00
S 15 167.50 6197.50 0.00
H 7 14.00 1011.00 0.00
T 0 1695.25 19092.00 19092.00
327 7426.49 193062.48 225.00
Other 0 147.50 1107.70 0.00
-------------------------------------------------
Total 522 16854.74 382090.00 83606.50
Center 53
Flag Claims Units Chgs Paid
-------------------------------------------------
R 28 197.75 9751.75 0.00
U 0 0.00 0.00 0.00
B 21 2006.25 86642.50 0.00
P 93 5329.07 70875.61 70279.08
D 0 65.00 4603.50 0.00
S 0 167.50 6197.50 0.00
H 0 14.00 1011.00 0.00
T 0 1695.25 19092.00 19092.00
452 11598.92 210725.65 225.00
Other 1 149.50 1218.70 83.25
-------------------------------------------------
Total 595 21223.24 410118.21 89679.33
Center 54
Flag Claims Units Chgs Paid
-------------------------------------------------
R 1 198.75 9801.75 0.00
U 0 0.00 0.00 0.00
B 238 2210.00 95925.75 0.00
P 362 9198.48 85010.48 84413.95
D 0 65.00 4603.50 0.00
S 0 167.50 6197.50 0.00
H 0 14.00 1011.00 0.00
T 0 1695.25 19092.00 19092.00
629 14571.26 234559.30 225.00
Other 0 149.50 1218.70 83.25
-------------------------------------------------
Total 1230 28269.74 457419.98 103814.20
Center 55
Flag Claims Units Chgs Paid
-------------------------------------------------
R 0 198.75 9801.75 0.00
U 0 0.00 0.00 0.00
B 25 2232.00 96739.75 0.00
P 72 9281.95 88810.21 88213.68
D 8 75.00 5030.50 0.00
S 0 167.50 6197.50 0.00
H 0 14.00 1011.00 0.00
T 3 1700.75 19426.50 19426.50
138 14728.04 241264.82 225.00
Other 0 149.50 1218.70 83.25
-------------------------------------------------
Total 246 28547.49 469500.73 107948.43
Center 57
Flag Claims Units Chgs Paid
-------------------------------------------------
R 5 202.50 9940.50 0.00
U 0 0.00 0.00 0.00
B 35 2289.00 99319.25 0.00
P 0 9281.95 88810.21 88213.68
D 0 75.00 5030.50 0.00
S 0 167.50 6197.50 0.00
H 0 14.00 1011.00 0.00
T 0 1700.75 19426.50 19426.50
137 14896.79 248207.82 225.00
Other 0 149.50 1218.70 83.25
-------------------------------------------------
Total 177 28776.99 479161.98 107948.43