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: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 2 2.25 83.25 37.00
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 5 5.00 0.00 0.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 36 56.00 2072.00 37.00
Subtotal (Total Children Is Unduplicated) 42 63.25 2155.25 34.08
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Screening, Eval, and Assessment,Class #02
ASTE-ASTE-ASSISTIVE TECHNOLOGY EVAL 2 3.00 122.00 40.67
AUDE-92552-PURE TONE AUDIOMETRY -AIR ONLY 3 3.00 31.86 10.62
AUDE-92553-PURE TONE AUDIOMETRY AIR & BONE 3 3.00 48.90 16.30
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 97 98.00 865.34 8.83
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 86 88.00 949.56 10.79
AUDE-92568-ACOUSTIC REFLEX TESTING (MEMR) 4 4.00 33.76 8.44
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 98 100.00 2179.00 21.79
AUDE-92585-AUD EVOKED RESPONSE (DIAG) 2 2.00 108.76 54.38
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 3 3.71 105.10 28.33
AUDE-92588-OTOACOUSTIC EMISSIONS (COMP) 7 9.00 263.31 29.26
AUDE-V5090-DISPENSING FEE PER HEARING AID 1 2.00 100.23 50.12
BEHV-H0031HO-COMP BEHAVIORAL HEALTH ASSESSMENT 1 1.00 125.00 125.00
EVAL-EVAL-DEVELOPMENTAL EVALUATION 1 1.50 75.00 50.00
EXIT-EXIT-TRANSITION ASSESSMENT 5 5.75 287.50 50.00
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 27 44.18 3314.14 75.01
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 9 14.00 1050.00 75.00
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 7 10.00 750.00 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 33 53.50 4012.50 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 12 18.50 1026.75 55.50
IPDEI-IPDEI_NM-INITIAL PSYCH & DEV EVAL BY NON-MED PR 7 12.50 693.75 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 338 519.19 39080.42 75.27
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 160 260.16 19438.26 74.72
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 110 162.56 12173.16 74.88
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 172 298.88 16948.62 56.71
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 126 201.24 15436.95 76.71
MED-99204-OUTPATIENT VISIT, NEW, 45 MINS 10 10.00 572.70 57.27
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 2 2.00 97.00 48.50
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 44 45.63 2193.15 48.06
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 2 1.25 62.48 49.98
PSTH-97001-EVAL BY LICENSED PT, INITIAL 30 29.75 1443.29 48.51
SCREEN-T1023-INTERDISCIPLINARY SCREENING 2 2.00 100.00 50.00
SPCH-92506-SPEECH EVAL BY LICENSED SLP 105 111.69 5403.87 48.38
Subtotal (Total Children Is Unduplicated) 810 2120.99 129092.36 60.86
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 7 17.00 3479.88 204.70
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 8 9.25 462.50 50.00
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 3 2.00 100.00 50.00
CONIP-CONIP-CONSULT, ITDS, PHONE 2 0.75 18.75 25.00
CONOF-CONOF-CONSULT, OT, FACE TO FACE 4 3.00 150.00 50.00
CONPF-CONPF-CONSULT, PT, FACE TO FACE 1 0.75 37.50 50.00
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 3 2.50 125.00 50.00
CONSP-CONSP-CONSULT, SLP, PHONE 1 1.00 25.00 25.00
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 2 2.00 50.00 25.00
EIIF-96154-HEALTH AND BEHAVIOR INTERVENTION 4 15.00 750.00 50.00
EIIF-EIIF_NM-EI INDIVIDUAL SESSION BY NONMED PROF 14 45.50 2287.50 50.27
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 145 613.70 30787.78 50.17
OCCT-97530-OT SESSION BY LICENSED OT 582 2313.45 157883.32 68.25
OCCT-97530HM-OT SESSION BY OT ASST 16 68.30 3709.58 54.31
PHY-97110-PT SESSION BY LICENSED PT 627 2570.39 173917.92 67.66
PHY-97110HM-PT SESSION BY PT ASST 24 77.57 4220.52 54.41
SENS-V5264-EARMOLD 4 6.00 112.32 18.72
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 1215 4732.31 321226.19 67.88
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 7 18.00 975.17 54.18
SPL-92508-GROUP SPL SESSION PER CHILD 18 40.53 542.15 13.38
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 39 5810.00 3187.80 0.55
Subtotal (Total Children Is Unduplicated) 2033 16349.0 704048.88 43.06
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Total 18533.24 835296.49 45.07
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Number of Children (Unduplicated) With at Least One Service 2601
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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 1 1.00 67.88 0.00
D 82 135.00 8924.00 0.00
S 1 0.50 18.50 0.00
H 2 3.50 262.50 0.00
T 0 0.00 0.00 0.00
746 1345.75 66607.60 0.00
Other 467 660.25 43108.46 0.00
-------------------------------------------------
Total 1299 2146.00 118988.94 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 1.00 67.88 0.00
D 0 135.00 8924.00 0.00
S 0 0.50 18.50 0.00
H 0 3.50 262.50 0.00
T 0 0.00 0.00 0.00
5 1355.75 67281.60 0.00
Other 0 660.25 43108.46 0.00
-------------------------------------------------
Total 5 2156.00 119662.94 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 1.00 67.88 0.00
D 0 135.00 8924.00 0.00
S 0 0.50 18.50 0.00
H 0 3.50 262.50 0.00
T 0 0.00 0.00 0.00
25 1379.75 68478.28 0.00
Other 57 717.25 43940.55 0.00
-------------------------------------------------
Total 82 2237.00 121691.71 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 15 50.00 2749.06 3064.37
D 0 135.00 8924.00 0.00
S 0 0.50 18.50 0.00
H 182 368.25 24604.37 24341.87
T 0 0.00 0.00 0.00
0 1379.75 68478.28 0.00
Other 0 717.25 43940.55 0.00
-------------------------------------------------
Total 197 2650.75 148714.76 27406.24
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 50.00 2749.06 3064.37
D 0 135.00 8924.00 0.00
S 0 0.50 18.50 0.00
H 0 368.25 24604.37 24341.87
T 0 0.00 0.00 0.00
522 1759.18 87556.00 0.00
Other 0 717.25 43940.55 0.00
-------------------------------------------------
Total 522 3030.18 167792.48 27406.24
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 50.00 2749.06 3064.37
D 0 135.00 8924.00 0.00
S 0 0.50 18.50 0.00
H 0 368.25 24604.37 24341.87
T 0 0.00 0.00 0.00
1748 3258.93 179088.66 0.00
Other 0 717.25 43940.55 0.00
-------------------------------------------------
Total 1748 4529.93 259325.14 27406.24
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 51 211.25 12122.59 12437.90
D 0 135.00 8924.00 0.00
S 0 0.50 18.50 0.00
H 0 368.25 24604.37 24341.87
T 0 0.00 0.00 0.00
188 7556.18 208503.24 0.00
Other 0 717.25 43940.55 0.00
-------------------------------------------------
Total 239 8988.43 298113.25 36779.77
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 21 228.75 13251.44 15194.92
D 0 135.00 8924.00 0.00
S 0 0.50 18.50 0.00
H 0 368.25 24604.37 24341.87
T 0 0.00 0.00 0.00
1413 9707.18 355573.59 114.11
Other 0 717.25 43940.55 0.00
-------------------------------------------------
Total 1434 11156.93 446312.45 39650.90
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 0 228.75 13251.44 15194.92
D 0 135.00 8924.00 0.00
S 0 0.50 18.50 0.00
H 0 368.25 24604.37 24341.87
T 0 0.00 0.00 0.00
1100 11552.93 478767.07 114.11
Other 0 717.25 43940.55 0.00
-------------------------------------------------
Total 1100 13002.68 569505.93 39650.90
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 22 290.75 17187.33 19130.81
D 0 135.00 8924.00 0.00
S 0 0.50 18.50 0.00
H 0 368.25 24604.37 24341.87
T 0 0.00 0.00 0.00
195 12020.68 509773.42 114.11
Other 0 717.25 43940.55 0.00
-------------------------------------------------
Total 217 13532.43 604448.17 43586.79
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 5 295.67 17810.80 19754.28
D 0 135.00 8924.00 0.00
S 0 0.50 18.50 0.00
H 31 427.50 28791.92 24341.87
T 0 0.00 0.00 0.00
448 12990.50 572404.76 114.11
Other 0 717.25 43940.55 0.00
-------------------------------------------------
Total 484 14566.42 671890.53 44210.26
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 14 311.06 19785.85 20790.60
D 0 135.00 8924.00 0.00
S 0 0.50 18.50 0.00
H 0 427.50 28791.92 24341.87
T 0 0.00 0.00 0.00
805 13535.36 606192.49 114.11
Other 0 717.25 43940.55 0.00
-------------------------------------------------
Total 819 15126.67 707653.31 45246.58
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 0 311.06 19785.85 20790.60
D 0 135.00 8924.00 0.00
S 0 0.50 18.50 0.00
H 0 427.50 28791.92 24341.87
T 0 0.00 0.00 0.00
549 15651.68 648645.02 114.11
Other 0 717.25 43940.55 0.00
-------------------------------------------------
Total 549 17242.99 750105.84 45246.58
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 1 312.06 19853.73 20858.48
D 0 135.00 8924.00 0.00
S 0 0.50 18.50 0.00
H 1 429.00 29041.92 24341.87
T 0 0.00 0.00 0.00
739 16175.32 682818.66 114.11
Other 0 717.25 43940.55 0.00
-------------------------------------------------
Total 741 17769.13 784597.36 45314.46
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 0.00 0.00 0.00
P 0 312.06 19853.73 20858.48
D 0 135.00 8924.00 0.00
S 0 0.50 18.50 0.00
H 0 429.00 29041.92 24341.87
T 4 7.00 455.78 455.78
463 16932.43 733062.01 49055.48
Other 0 717.25 43940.55 0.00
-------------------------------------------------
Total 467 18533.24 835296.49 94711.61