CMS/EIP Fiscal Report Statewide
Services beginning 04/01/2010 ending 06/30/2010 Date of Report:08/18/2010 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
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 1 1.00 37.00 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 1 0.75 27.75 37.00
Subtotal (Total Children Is Unduplicated) 2 1.75 64.75 37.00
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Screening, Eval, and Assessment,Class #02
AUDE-92552-PURE TONE AUDIOMETRY -AIR ONLY 5 5.00 53.10 10.62
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 14 14.00 123.62 8.83
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 9 9.00 96.36 10.71
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 15 15.00 326.85 21.79
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 5 5.00 141.40 28.28
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 9 14.50 1087.50 75.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 3 5.00 375.00 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 9 14.50 1087.50 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 10 15.50 860.25 55.50
IPDEI-IPDEI_NM-INITIAL PSYCH & DEV EVAL BY NON-MED PR 1 2.00 111.00 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 200 274.20 20719.09 75.56
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 70 106.05 8302.73 78.29
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 42 54.33 4074.75 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 160 236.00 13873.70 58.79
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 86 122.55 9831.37 80.22
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 2 2.00 370.00 185.00
MED-99204-OUTPATIENT VISIT, NEW, 45 MINS 1 1.00 57.27 57.27
SPCH-92506-SPEECH EVAL BY LICENSED SLP 5 9.00 436.50 48.50
Subtotal (Total Children Is Unduplicated) 324 904.63 61927.99 68.46
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 1 2.00 100.00 50.00
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 1 10.75 800.87 74.50
Subtotal (Total Children Is Unduplicated) 2 12.75 900.87 70.66
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Total 919.13 62893.61 68.43
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Number of Children (Unduplicated) With at Least One Service 328
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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 45 60.00 3495.75 0.00
S 2 3.00 225.00 0.00
H 3 4.50 337.50 0.00
T 0 0.00 0.00 0.00
7 4.75 393.59 0.00
Other 77 108.00 7971.03 0.00
-------------------------------------------------
Total 134 180.25 12422.87 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 0.00 0.00 0.00
S 0 0.00 0.00 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
0 0.00 0.00 0.00
Other 17 17.00 257.73 0.00
-------------------------------------------------
Total 17 17.00 257.73 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 5 5.00 575.50 1153.49
D 0 0.00 0.00 0.00
S 0 0.00 0.00 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
0 0.00 0.00 0.00
Other 0 0.00 0.00 0.00
-------------------------------------------------
Total 5 5.00 575.50 1153.49
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 0.00 0.00 0.00
D 0 0.00 0.00 0.00
S 0 0.00 0.00 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
2 2.00 150.00 0.00
Other 0 0.00 0.00 0.00
-------------------------------------------------
Total 2 2.00 150.00 0.00
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 0.00 0.00 0.00
D 0 0.00 0.00 0.00
S 0 0.00 0.00 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
48 58.50 3973.36 0.00
Other 0 0.00 0.00 0.00
-------------------------------------------------
Total 48 58.50 3973.36 0.00
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 0.00 0.00 0.00
D 0 0.00 0.00 0.00
S 0 0.00 0.00 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
2 4.00 300.00 0.00
Other 0 0.00 0.00 0.00
-------------------------------------------------
Total 2 4.00 300.00 0.00
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 0.00 0.00 0.00
D 0 0.00 0.00 0.00
S 0 0.00 0.00 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
146 170.50 12004.50 0.00
Other 0 0.00 0.00 0.00
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Total 146 170.50 12004.50 0.00
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 0.00 0.00 0.00
D 0 0.00 0.00 0.00
S 0 0.00 0.00 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
184 286.50 18268.01 0.00
Other 0 0.00 0.00 0.00
-------------------------------------------------
Total 184 286.50 18268.01 0.00
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 0.00 0.00 0.00
D 0 0.00 0.00 0.00
S 0 0.00 0.00 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
2 2.00 123.50 0.00
Other 0 0.00 0.00 0.00
-------------------------------------------------
Total 2 2.00 123.50 0.00
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 1 1.50 83.25 0.00
D 0 0.00 0.00 0.00
S 0 0.00 0.00 0.00
H 1 1.00 55.50 0.00
T 0 0.00 0.00 0.00
36 51.83 3390.00 0.00
Other 0 0.00 0.00 0.00
-------------------------------------------------
Total 38 54.33 3528.75 0.00
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 0 0.00 0.00 0.00
D 0 0.00 0.00 0.00
S 0 0.00 0.00 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
23 44.00 4603.82 0.00
Other 0 0.00 0.00 0.00
-------------------------------------------------
Total 23 44.00 4603.82 0.00
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 0.00 0.00 0.00
D 0 0.00 0.00 0.00
S 0 0.00 0.00 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
53 82.01 5570.12 0.00
Other 0 0.00 0.00 0.00
-------------------------------------------------
Total 53 82.01 5570.12 0.00
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 1.00 75.00 75.00
D 0 0.00 0.00 0.00
S 0 0.00 0.00 0.00
H 1 1.00 250.00 0.00
T 0 0.00 0.00 0.00
8 11.04 790.45 0.00
Other 0 0.00 0.00 0.00
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Total 10 13.04 1115.45 75.00