CMS/EIP Fiscal Report Statewide
Services beginning 10/01/2009 ending 12/31/2009 Date of Report:02/16/2010 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 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
AUDE-92553-PURE TONE AUDIOMETRY AIR & BONE 2 2.00 32.60 16.30
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 79 79.00 697.57 8.83
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 62 62.00 669.60 10.80
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 76 76.00 1656.04 21.79
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 1 1.00 28.28 28.28
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 25 42.00 3150.00 75.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 7 10.50 787.50 75.00
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 6 8.50 637.50 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 31 52.00 3900.00 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 4 7.50 416.25 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 267 414.04 31419.15 75.88
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 144 233.50 17512.50 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 72 107.06 8029.85 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 169 293.88 16679.37 56.76
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 124 198.74 15249.45 76.73
MED-99204-OUTPATIENT VISIT, NEW, 45 MINS 10 10.00 572.70 57.27
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 1 1.00 48.50 48.50
SCREEN-T1023-INTERDISCIPLINARY SCREENING 2 2.00 100.00 50.00
SPCH-92506-SPEECH EVAL BY LICENSED SLP 1 1.00 48.50 48.50
Subtotal (Total Children Is Unduplicated) 549 1620.22 102662.11 63.36
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 1 1.50 75.00 50.00
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 2 2.00 50.00 25.00
EIIF-EIIF_NM-EI INDIVIDUAL SESSION BY NONMED PROF 1 1.00 50.00 50.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 54 219.00 10950.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 19 48.78 3467.19 71.08
PHY-97110-PT SESSION BY LICENSED PT 10 25.50 1730.94 67.88
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 39 209.31 14339.71 68.51
SPL-92508-GROUP SPL SESSION PER CHILD 3 10.50 138.60 13.20
Subtotal (Total Children Is Unduplicated) 120 517.59 30801.44 59.51
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Total 2201.06 135618.80 61.62
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Number of Children (Unduplicated) With at Least One Service 689
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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 79 131.00 8713.00 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
46 32.00 1184.00 0.00
Other 7 9.50 712.50 0.00
-------------------------------------------------
Total 135 176.50 10890.50 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 0 131.00 8713.00 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
1 34.00 1258.00 0.00
Other 0 9.50 712.50 0.00
-------------------------------------------------
Total 1 178.50 10964.50 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 0 131.00 8713.00 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
0 34.00 1258.00 0.00
Other 57 66.50 1544.59 0.00
-------------------------------------------------
Total 57 235.50 11796.59 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 3 3.00 186.00 569.19
D 0 131.00 8713.00 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
0 34.00 1258.00 0.00
Other 0 66.50 1544.59 0.00
-------------------------------------------------
Total 3 238.50 11982.59 569.19
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 3.00 186.00 569.19
D 0 131.00 8713.00 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
351 473.00 24032.70 0.00
Other 0 66.50 1544.59 0.00
-------------------------------------------------
Total 351 677.50 34757.29 569.19
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 3.00 186.00 569.19
D 0 131.00 8713.00 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
17 487.50 24569.20 0.00
Other 0 66.50 1544.59 0.00
-------------------------------------------------
Total 17 692.00 35293.79 569.19
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 2 4.50 287.82 752.19
D 0 131.00 8713.00 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
279 861.25 50739.06 0.00
Other 0 66.50 1544.59 0.00
-------------------------------------------------
Total 281 1067.25 61565.47 752.19
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 4.50 287.82 752.19
D 0 131.00 8713.00 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
239 1287.75 80181.81 0.00
Other 0 66.50 1544.59 0.00
-------------------------------------------------
Total 239 1493.75 91008.22 752.19
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 0 4.50 287.82 752.19
D 0 131.00 8713.00 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
3 1290.75 80385.45 0.00
Other 0 66.50 1544.59 0.00
-------------------------------------------------
Total 3 1496.75 91211.86 752.19
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 9.42 911.29 1375.66
D 0 131.00 8713.00 0.00
S 0 0.50 18.50 0.00
H 30 61.25 4337.55 0.00
T 0 0.00 0.00 0.00
105 1501.50 93131.33 0.00
Other 0 66.50 1544.59 0.00
-------------------------------------------------
Total 140 1770.17 108656.26 1375.66
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 24.81 2886.34 2411.98
D 0 131.00 8713.00 0.00
S 0 0.50 18.50 0.00
H 0 61.25 4337.55 0.00
T 0 0.00 0.00 0.00
32 1560.50 96989.10 0.00
Other 0 66.50 1544.59 0.00
-------------------------------------------------
Total 46 1844.56 114489.08 2411.98
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 24.81 2886.34 2411.98
D 0 131.00 8713.00 0.00
S 0 0.50 18.50 0.00
H 0 61.25 4337.55 0.00
T 0 0.00 0.00 0.00
311 1892.25 116210.57 0.00
Other 0 66.50 1544.59 0.00
-------------------------------------------------
Total 311 2176.31 133710.55 2411.98
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 24.81 2886.34 2411.98
D 0 131.00 8713.00 0.00
S 0 0.50 18.50 0.00
H 1 62.75 4587.55 0.00
T 0 0.00 0.00 0.00
16 1915.50 117868.82 0.00
Other 0 66.50 1544.59 0.00
-------------------------------------------------
Total 17 2201.06 135618.80 2411.98