CMS/EIP Fiscal Report Statewide
Services beginning 01/01/2010 ending 03/31/2010 Date of Report:05/17/2010 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 1 0.25 9.25 37.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 1 0.25 9.25 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 27 59.00 2183.00 37.00
Subtotal (Total Children Is Unduplicated) 27 59.50 2201.50 37.00
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Screening, Eval, and Assessment,Class #02
ASTE-ASTE-ASSISTIVE TECHNOLOGY EVAL 1 1.00 47.00 47.00
AUDE-92552-PURE TONE AUDIOMETRY -AIR ONLY 7 7.00 82.01 11.72
AUDE-92553-PURE TONE AUDIOMETRY AIR & BONE 5 5.00 81.50 16.30
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 121 123.00 1081.80 8.80
AUDE-92557-COMP AUDIO THRESHOLD EVAL/SPCH RECOG 1 1.00 27.10 27.10
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 100 104.00 1115.93 10.73
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 119 122.00 2651.46 21.73
AUDE-92585-AUD EVOKED RESPONSE (DIAG) 3 3.00 156.30 52.10
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 7 7.00 172.03 24.58
AUDE-92588-OTOACOUSTIC EMISSIONS (COMP) 15 16.00 508.96 31.81
EVAL-EVAL-DEVELOPMENTAL EVALUATION 4 10.00 550.00 55.00
EXIT-EXIT-TRANSITION ASSESSMENT 12 25.25 1262.50 50.00
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 68 112.50 8437.50 75.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 12 20.00 1500.00 75.00
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 11 16.00 1200.00 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 48 92.00 7037.50 76.49
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 25 45.00 2497.50 55.50
IPDEI-IPDEI_NM-INITIAL PSYCH & DEV EVAL BY NON-MED PR 26 42.74 5962.73 139.51
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 609 878.08 66568.55 75.81
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 257 402.64 30314.09 75.29
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 158 214.37 16194.39 75.54
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 370 569.42 35786.15 62.85
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 270 384.08 34382.39 89.52
MED-99202-OUTPATIENT VISIT, NEW, 20 MINS 2 2.00 54.44 27.22
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 3 3.00 555.00 185.00
MED-99204-OUTPATIENT VISIT, NEW, 45 MINS 7 7.00 400.89 57.27
MED-99205-OUTPATIENT VISIT, NEW, 60 MINS 1 2.00 145.56 72.78
MED-99215-OUTPATIENT VISIT, EST, 40 MINS 1 1.00 50.15 50.15
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 2 2.00 97.00 48.50
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 60 64.51 3002.50 46.54
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 5 4.47 217.16 48.58
PSTH-97001-EVAL BY LICENSED PT, INITIAL 30 29.75 1444.50 48.55
SCREEN-T1023-INTERDISCIPLINARY SCREENING 8 8.00 400.00 50.00
SENS-V5014TS-HEARING AID REPAIR IN-OFFICE 1 1.00 15.00 15.00
SPCH-92506-SPEECH EVAL BY LICENSED SLP 123 125.52 6087.50 48.50
Subtotal (Total Children Is Unduplicated) 1261 3451.33 230087.09 66.67
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 13 48.00 7592.10 158.17
AUD-92633-AUD REHAB POSTLING HEARING LOSS 1 1.00 68.86 68.86
AUD-HA_FUP-AUDIOLOGY SERVICES 1 1.00 50.00 50.00
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 12 19.50 975.00 50.00
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 14 12.50 625.00 50.00
CONIP-CONIP-CONSULT, ITDS, PHONE 2 1.00 25.00 25.00
CONOF-CONOF-CONSULT, OT, FACE TO FACE 1 1.00 50.00 50.00
CONOP-CONOP-CONSULT, OT, PHONE 1 1.00 25.00 25.00
CONPF-CONPF-CONSULT, PT, FACE TO FACE 4 4.25 212.50 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 1.00 50.00 50.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 183 906.35 45466.99 50.16
HERN-T1027SC-EI HEARING SERVICES AFTER SHINE 7 15.00 750.00 50.00
INTR-INTR-INTERPRETER 1 2.00 100.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 577 2437.77 167965.38 68.90
OCCT-97530HM-OT SESSION BY OT ASST 25 109.98 6587.46 59.90
PHY-97110-PT SESSION BY LICENSED PT 601 2667.02 179375.10 67.26
PHY-97110HM-PT SESSION BY PT ASST 25 68.50 3931.96 57.40
SENS-V5264-EARMOLD 3 8.00 148.32 18.54
SHIN-T1027SC-INITIAL SHINE SERVICES, INDIVIDUAL 1 1.00 50.00 50.00
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 1169 4706.11 319724.07 67.94
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 11 22.25 1227.98 55.19
SPL-92508-GROUP SPL SESSION PER CHILD 10 25.50 336.60 13.20
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 21 2079.00 1076.70 0.52
Subtotal (Total Children Is Unduplicated) 1947 13139.7 736464.02 56.05
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Total 16650.56 968752.61 58.18
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Number of Children (Unduplicated) With at Least One Service 2904
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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 7 7.50 509.14 135.76
D 153 198.50 12243.75 0.00
S 0 0.00 0.00 0.00
H 15 25.50 1695.56 0.00
T 0 0.00 0.00 0.00
531 731.14 43849.24 135.76
Other 962 1007.50 66497.05 0.00
-------------------------------------------------
Total 1668 1970.14 124794.74 271.52
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 7.50 509.14 135.76
D 0 198.50 12243.75 0.00
S 0 0.00 0.00 0.00
H 0 25.50 1695.56 0.00
T 0 0.00 0.00 0.00
9 750.14 45046.24 135.76
Other 0 1007.50 66497.05 0.00
-------------------------------------------------
Total 9 1989.14 125991.74 271.52
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 7.50 509.14 135.76
D 0 198.50 12243.75 0.00
S 0 0.00 0.00 0.00
H 0 25.50 1695.56 0.00
T 0 0.00 0.00 0.00
8 758.14 45446.24 135.76
Other 56 1063.50 67329.14 0.00
-------------------------------------------------
Total 64 2053.14 127223.83 271.52
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 17 44.50 2823.64 3197.97
D 0 198.50 12243.75 0.00
S 0 0.00 0.00 0.00
H 153 331.50 22179.14 20483.58
T 0 0.00 0.00 0.00
0 758.14 45446.24 135.76
Other 0 1063.50 67329.14 0.00
-------------------------------------------------
Total 170 2396.14 150021.91 23817.31
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 44.50 2823.64 3197.97
D 0 198.50 12243.75 0.00
S 0 0.00 0.00 0.00
H 0 331.50 22179.14 20483.58
T 0 0.00 0.00 0.00
767 1562.00 75361.46 135.76
Other 0 1063.50 67329.14 0.00
-------------------------------------------------
Total 767 3200.00 179937.13 23817.31
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 44.50 2823.64 3197.97
D 0 198.50 12243.75 0.00
S 0 0.00 0.00 0.00
H 0 331.50 22179.14 20483.58
T 0 0.00 0.00 0.00
1631 3048.25 161144.31 135.76
Other 0 1063.50 67329.14 0.00
-------------------------------------------------
Total 1631 4686.25 265719.98 23817.31
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 51 241.50 14486.34 14860.67
D 0 198.50 12243.75 0.00
S 0 0.00 0.00 0.00
H 0 331.50 22179.14 20483.58
T 0 0.00 0.00 0.00
183 4704.75 186644.24 135.76
Other 0 1063.50 67329.14 0.00
-------------------------------------------------
Total 234 6539.75 302882.61 35480.01
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 24 253.75 15304.31 16622.27
D 0 198.50 12243.75 0.00
S 0 0.00 0.00 0.00
H 0 331.50 22179.14 20483.58
T 0 0.00 0.00 0.00
1648 7242.75 360570.26 135.76
Other 0 1063.50 67329.14 0.00
-------------------------------------------------
Total 1672 9090.00 477626.60 37241.61
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 0 253.75 15304.31 16622.27
D 0 198.50 12243.75 0.00
S 0 0.00 0.00 0.00
H 0 331.50 22179.14 20483.58
T 0 0.00 0.00 0.00
1376 9455.50 509219.46 135.76
Other 0 1063.50 67329.14 0.00
-------------------------------------------------
Total 1376 11302.75 626275.80 37241.61
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 46 394.75 20382.32 21700.28
D 0 198.50 12243.75 0.00
S 0 0.00 0.00 0.00
H 0 331.50 22179.14 20483.58
T 0 0.00 0.00 0.00
207 9871.75 537801.27 135.76
Other 0 1063.50 67329.14 0.00
-------------------------------------------------
Total 253 11860.00 659935.62 42319.62
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 4 400.41 20778.79 22096.75
D 0 198.50 12243.75 0.00
S 0 0.00 0.00 0.00
H 44 407.00 27168.43 20483.58
T 0 0.00 0.00 0.00
588 11123.55 617789.77 135.76
Other 0 1063.50 67329.14 0.00
-------------------------------------------------
Total 636 13192.96 745309.88 42716.09
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 10 408.16 21285.33 22603.29
D 0 198.50 12243.75 0.00
S 0 0.00 0.00 0.00
H 0 407.00 27168.43 20483.58
T 0 0.00 0.00 0.00
788 11758.98 669628.76 135.76
Other 0 1063.50 67329.14 0.00
-------------------------------------------------
Total 798 13836.14 797655.41 43222.63
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 0 408.16 21285.33 22603.29
D 0 198.50 12243.75 0.00
S 0 0.00 0.00 0.00
H 0 407.00 27168.43 20483.58
T 0 0.00 0.00 0.00
668 12705.11 714568.32 135.76
Other 0 1063.50 67329.14 0.00
-------------------------------------------------
Total 668 14782.27 842594.97 43222.63
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 1 409.66 21535.33 22765.79
D 0 198.50 12243.75 0.00
S 0 0.00 0.00 0.00
H 17 424.00 31243.43 20483.58
T 0 0.00 0.00 0.00
1009 13439.38 763720.54 135.76
Other 0 1063.50 67329.14 0.00
-------------------------------------------------
Total 1027 15535.04 896072.19 43385.13
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 0 409.66 21535.33 22765.79
D 0 198.50 12243.75 0.00
S 4 6.50 402.46 402.46
H 0 424.00 31243.43 20483.58
T 4 24.50 329.20 329.20
486 14523.90 835669.30 38038.20
Other 0 1063.50 67329.14 0.00
-------------------------------------------------
Total 494 16650.56 968752.61 82019.23