CMS/EIP Fiscal Report Statewide
Services beginning 10/01/2009 ending 12/31/2009 Date of Report:02/16/2010 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 7 7.25 268.25 37.00
Subtotal (Total Children Is Unduplicated) 7 7.25 268.25 37.00
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Screening, Eval, and Assessment,Class #02
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 2 2.00 17.66 8.83
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 2 2.00 21.60 10.80
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 2 2.00 43.58 21.79
AUDE-92585-AUD EVOKED RESPONSE (DIAG) 1 1.00 54.38 54.38
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 1 1.00 28.28 28.28
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 9 16.00 1200.00 75.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 6 9.00 675.00 75.00
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 2 4.00 300.00 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 7 11.00 825.00 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 9 14.50 804.75 55.50
IPDEI-IPDEI_NM-INITIAL PSYCH & DEV EVAL BY NON-MED PR 2 4.30 404.89 94.16
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 117 164.62 12154.65 73.83
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 63 86.15 6461.60 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 39 52.84 3962.96 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 101 170.26 9615.59 56.48
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 55 75.17 5804.87 77.22
Subtotal (Total Children Is Unduplicated) 215 615.84 42374.81 68.81
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Total 623.09 42643.06 68.44
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Number of Children (Unduplicated) With at Least One Service 222
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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 16 30.50 2102.25 0.00
S 0 0.00 0.00 0.00
H 2 3.50 262.50 0.00
T 0 0.00 0.00 0.00
11 7.25 268.25 0.00
Other 0 0.00 0.00 0.00
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Total 29 41.25 2633.00 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 30.50 2102.25 0.00
S 0 0.00 0.00 0.00
H 0 3.50 262.50 0.00
T 0 0.00 0.00 0.00
1 9.25 418.25 0.00
Other 0 0.00 0.00 0.00
-------------------------------------------------
Total 1 43.25 2783.00 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 30.50 2102.25 0.00
S 0 0.00 0.00 0.00
H 0 3.50 262.50 0.00
T 0 0.00 0.00 0.00
0 9.25 418.25 0.00
Other 5 5.00 124.08 0.00
-------------------------------------------------
Total 5 48.25 2907.08 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 1 1.00 75.00 66.18
D 0 30.50 2102.25 0.00
S 0 0.00 0.00 0.00
H 0 3.50 262.50 0.00
T 0 0.00 0.00 0.00
0 9.25 418.25 0.00
Other 0 5.00 124.08 0.00
-------------------------------------------------
Total 1 49.25 2982.08 66.18
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 1.00 75.00 66.18
D 0 30.50 2102.25 0.00
S 0 0.00 0.00 0.00
H 0 3.50 262.50 0.00
T 0 0.00 0.00 0.00
2 11.95 468.81 0.00
Other 0 5.00 124.08 0.00
-------------------------------------------------
Total 2 51.95 3032.64 66.18
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 1.00 75.00 66.18
D 0 30.50 2102.25 0.00
S 0 0.00 0.00 0.00
H 0 3.50 262.50 0.00
T 0 0.00 0.00 0.00
55 74.45 4953.23 0.00
Other 0 5.00 124.08 0.00
-------------------------------------------------
Total 55 114.45 7517.06 66.18
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 1.00 75.00 66.18
D 0 30.50 2102.25 0.00
S 0 0.00 0.00 0.00
H 0 3.50 262.50 0.00
T 0 0.00 0.00 0.00
1 76.45 5103.23 0.00
Other 0 5.00 124.08 0.00
-------------------------------------------------
Total 1 116.45 7667.06 66.18
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 1.00 75.00 66.18
D 0 30.50 2102.25 0.00
S 0 0.00 0.00 0.00
H 0 3.50 262.50 0.00
T 0 0.00 0.00 0.00
82 182.45 12702.23 0.00
Other 0 5.00 124.08 0.00
-------------------------------------------------
Total 82 222.45 15266.06 66.18
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 1.00 75.00 66.18
D 0 30.50 2102.25 0.00
S 0 0.00 0.00 0.00
H 0 3.50 262.50 0.00
T 0 0.00 0.00 0.00
179 474.45 32193.98 0.00
Other 0 5.00 124.08 0.00
-------------------------------------------------
Total 179 514.45 34757.81 66.18
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 1.00 75.00 66.18
D 0 30.50 2102.25 0.00
S 0 0.00 0.00 0.00
H 0 3.50 262.50 0.00
T 0 0.00 0.00 0.00
2 476.45 32343.98 0.00
Other 0 5.00 124.08 0.00
-------------------------------------------------
Total 2 516.45 34907.81 66.18
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 1.00 75.00 66.18
D 0 30.50 2102.25 0.00
S 0 0.00 0.00 0.00
H 7 14.00 1011.00 0.00
T 0 0.00 0.00 0.00
15 497.15 33515.44 0.00
Other 0 5.00 124.08 0.00
-------------------------------------------------
Total 22 547.65 36827.77 66.18
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 7.07 949.79 442.76
D 0 30.50 2102.25 0.00
S 0 0.00 0.00 0.00
H 0 14.00 1011.00 0.00
T 0 0.00 0.00 0.00
6 509.15 34288.69 0.00
Other 0 5.00 124.08 0.00
-------------------------------------------------
Total 12 565.72 38475.81 442.76
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 7.07 949.79 442.76
D 0 30.50 2102.25 0.00
S 0 0.00 0.00 0.00
H 0 14.00 1011.00 0.00
T 0 0.00 0.00 0.00
32 555.99 37665.92 0.00
Other 0 5.00 124.08 0.00
-------------------------------------------------
Total 32 612.56 41853.04 442.76
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 7.07 949.79 442.76
D 0 30.50 2102.25 0.00
S 0 0.00 0.00 0.00
H 0 14.00 1011.00 0.00
T 0 0.00 0.00 0.00
7 566.52 38455.94 0.00
Other 0 5.00 124.08 0.00
-------------------------------------------------
Total 7 623.09 42643.06 442.76