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: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 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 44 63.50 2349.50 37.00
Subtotal (Total Children Is Unduplicated) 50 70.75 2432.75 34.39
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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) 99 100.00 883.00 8.83
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 88 90.00 971.16 10.79
AUDE-92568-ACOUSTIC REFLEX TESTING (MEMR) 4 4.00 33.76 8.44
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 100 102.00 2222.58 21.79
AUDE-92585-AUD EVOKED RESPONSE (DIAG) 3 3.00 163.14 54.38
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 4 4.71 133.38 28.32
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 2 4.50 225.00 50.00
EXIT-EXIT-TRANSITION ASSESSMENT 5 5.75 287.50 50.00
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 36 60.18 4514.14 75.01
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 15 23.00 1725.00 75.00
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 9 14.00 1050.00 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 40 64.50 4837.50 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 21 33.00 1831.50 55.50
IPDEI-IPDEI_NM-INITIAL PSYCH & DEV EVAL BY NON-MED PR 9 16.80 1098.64 65.40
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 457 686.81 51460.07 74.93
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 225 348.81 26087.36 74.79
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 149 215.40 16136.12 74.91
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 274 471.14 26675.21 56.62
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 181 276.41 21241.82 76.85
MED-99204-OUTPATIENT VISIT, NEW, 45 MINS 10 10.00 572.70 57.27
MED-99205-OUTPATIENT VISIT, NEW, 60 MINS 1 1.00 72.78 72.78
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) 1029 2748.33 172213.45 62.66
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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 146 615.70 30887.78 50.17
OCCT-97530-OT SESSION BY LICENSED OT 583 2324.45 158630.00 68.24
OCCT-97530HM-OT SESSION BY OT ASST 16 68.30 3709.58 54.31
PHY-97110-PT SESSION BY LICENSED PT 628 2574.39 174189.44 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 1216 4732.81 321310.51 67.89
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) 2037 16366.5 705251.40 43.09
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Total 19185.58 879897.60 45.86
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Number of Children (Unduplicated) With at Least One Service 2830
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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 98 165.50 11026.25 0.00
S 1 0.50 18.50 0.00
H 4 7.00 525.00 0.00
T 0 0.00 0.00 0.00
759 1355.25 66985.10 0.00
Other 467 660.25 43108.46 0.00
-------------------------------------------------
Total 1330 2189.50 121731.19 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 0 165.50 11026.25 0.00
S 0 0.50 18.50 0.00
H 0 7.00 525.00 0.00
T 0 0.00 0.00 0.00
6 1367.25 67809.10 0.00
Other 0 660.25 43108.46 0.00
-------------------------------------------------
Total 6 2201.50 122555.19 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 0 165.50 11026.25 0.00
S 0 0.50 18.50 0.00
H 0 7.00 525.00 0.00
T 0 0.00 0.00 0.00
25 1391.25 69005.78 0.00
Other 62 722.25 44064.63 0.00
-------------------------------------------------
Total 87 2287.50 124708.04 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 16 51.00 2824.06 3130.55
D 0 165.50 11026.25 0.00
S 0 0.50 18.50 0.00
H 182 371.75 24866.87 24341.87
T 0 0.00 0.00 0.00
0 1391.25 69005.78 0.00
Other 0 722.25 44064.63 0.00
-------------------------------------------------
Total 198 2702.25 151806.09 27472.42
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 51.00 2824.06 3130.55
D 0 165.50 11026.25 0.00
S 0 0.50 18.50 0.00
H 0 371.75 24866.87 24341.87
T 0 0.00 0.00 0.00
528 1777.38 88356.84 0.00
Other 0 722.25 44064.63 0.00
-------------------------------------------------
Total 528 3088.38 171157.15 27472.42
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 51.00 2824.06 3130.55
D 0 165.50 11026.25 0.00
S 0 0.50 18.50 0.00
H 0 371.75 24866.87 24341.87
T 0 0.00 0.00 0.00
1814 3347.13 184907.94 0.00
Other 0 722.25 44064.63 0.00
-------------------------------------------------
Total 1814 4658.13 267708.25 27472.42
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 51 212.25 12197.59 12504.08
D 0 165.50 11026.25 0.00
S 0 0.50 18.50 0.00
H 0 371.75 24866.87 24341.87
T 0 0.00 0.00 0.00
189 7646.38 214472.52 0.00
Other 0 722.25 44064.63 0.00
-------------------------------------------------
Total 240 9118.63 306646.36 36845.95
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 21 229.75 13326.44 15261.10
D 0 165.50 11026.25 0.00
S 0 0.50 18.50 0.00
H 0 371.75 24866.87 24341.87
T 0 0.00 0.00 0.00
1495 9903.38 369141.87 114.11
Other 0 722.25 44064.63 0.00
-------------------------------------------------
Total 1516 11393.13 462444.56 39717.08
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 0 229.75 13326.44 15261.10
D 0 165.50 11026.25 0.00
S 0 0.50 18.50 0.00
H 0 371.75 24866.87 24341.87
T 0 0.00 0.00 0.00
1282 12045.63 512172.42 114.11
Other 0 722.25 44064.63 0.00
-------------------------------------------------
Total 1282 13535.38 605475.11 39717.08
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 22 291.75 17262.33 19196.99
D 0 165.50 11026.25 0.00
S 0 0.50 18.50 0.00
H 0 371.75 24866.87 24341.87
T 0 0.00 0.00 0.00
199 12526.38 544075.45 114.11
Other 0 722.25 44064.63 0.00
-------------------------------------------------
Total 221 14078.13 641314.03 43652.97
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 5 296.67 17885.80 19820.46
D 0 165.50 11026.25 0.00
S 0 0.50 18.50 0.00
H 38 441.50 29802.92 24341.87
T 0 0.00 0.00 0.00
463 13516.90 607878.25 114.11
Other 0 722.25 44064.63 0.00
-------------------------------------------------
Total 506 15143.32 710676.35 44276.44
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 20 318.13 20735.64 21233.36
D 0 165.50 11026.25 0.00
S 0 0.50 18.50 0.00
H 0 441.50 29802.92 24341.87
T 0 0.00 0.00 0.00
811 14073.76 642439.23 114.11
Other 0 722.25 44064.63 0.00
-------------------------------------------------
Total 831 15721.64 748087.17 45689.34
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 0 318.13 20735.64 21233.36
D 0 165.50 11026.25 0.00
S 0 0.50 18.50 0.00
H 0 441.50 29802.92 24341.87
T 0 0.00 0.00 0.00
581 16236.92 688268.99 114.11
Other 0 722.25 44064.63 0.00
-------------------------------------------------
Total 581 17884.80 793916.93 45689.34
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 1 319.13 20803.52 21301.24
D 0 165.50 11026.25 0.00
S 0 0.50 18.50 0.00
H 1 443.00 30052.92 24341.87
T 0 0.00 0.00 0.00
746 16771.09 723232.65 114.11
Other 0 722.25 44064.63 0.00
-------------------------------------------------
Total 748 18421.47 829198.47 45757.22
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 0 319.13 20803.52 21301.24
D 0 165.50 11026.25 0.00
S 0 0.50 18.50 0.00
H 0 443.00 30052.92 24341.87
T 4 7.00 455.78 455.78
463 17528.20 773476.00 49055.48
Other 0 722.25 44064.63 0.00
-------------------------------------------------
Total 467 19185.58 879897.60 95154.37