CMS/EIP Fiscal Report Statewide
Services beginning 04/01/2010 ending 06/30/2010 Date of Report:08/18/2010 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
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 6 6.00 0.00 0.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 1 0.50 18.50 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 21 75.25 2775.00 36.88
Subtotal (Total Children Is Unduplicated) 27 81.75 2793.50 34.17
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Screening, Eval, and Assessment,Class #02
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 81 82.00 724.06 8.83
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 65 66.00 712.80 10.80
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 79 80.00 1743.20 21.79
AUDE-92585-AUD EVOKED RESPONSE (DIAG) 1 1.00 54.38 54.38
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 3 4.00 113.12 28.28
AUDE-92588-OTOACOUSTIC EMISSIONS (COMP) 1 1.00 31.81 31.81
EXIT-EXIT-TRANSITION ASSESSMENT 1 1.00 50.00 50.00
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 56 94.00 7050.00 75.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 12 22.00 1650.00 75.00
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 2 2.50 187.50 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 34 60.00 4500.00 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 29 45.00 2497.50 55.50
IPDEI-IPDEI_NM-INITIAL PSYCH & DEV EVAL BY NON-MED PR 4 8.00 599.14 74.89
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 336 516.50 38853.64 75.22
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 142 234.00 17782.28 75.99
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 82 126.50 9603.64 75.92
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 256 411.00 23431.06 57.01
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 161 248.11 20344.84 82.00
MED-99202-OUTPATIENT VISIT, NEW, 20 MINS 4 4.00 108.88 27.22
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 20 20.00 3700.00 185.00
MED-99204-OUTPATIENT VISIT, NEW, 45 MINS 11 11.00 629.97 57.27
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 2 2.00 210.00 105.00
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 7 11.00 533.50 48.50
SCREEN-T1023-INTERDISCIPLINARY SCREENING 2 2.00 100.00 50.00
SPCH-92506-SPEECH EVAL BY LICENSED SLP 17 25.00 1212.50 48.50
Subtotal (Total Children Is Unduplicated) 701 2077.61 136423.82 65.66
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 4 7.00 350.00 50.00
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 4 3.50 175.00 50.00
CONPF-CONPF-CONSULT, PT, FACE TO FACE 2 1.50 75.00 50.00
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 1 2.00 100.00 50.00
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 4 12.00 300.00 25.00
EIIF-EIIF_NM-EI INDIVIDUAL SESSION BY NONMED PROF 1 44.75 2237.50 50.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 78 379.75 19012.50 50.07
HERN-T1027SC-EI HEARING SERVICES AFTER SHINE 1 3.00 150.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 14 93.75 6908.19 73.69
OCCT-97530HM-OT SESSION BY OT ASST 1 1.00 54.32 54.32
PHY-97110-PT SESSION BY LICENSED PT 13 39.75 2698.23 67.88
SHIN-T1027SC-INITIAL SHINE SERVICES, INDIVIDUAL 1 1.00 50.00 50.00
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 43 248.47 16883.24 67.95
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 1 24.00 12.00 0.50
Subtotal (Total Children Is Unduplicated) 154 861.47 49005.98 56.89
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Total 3020.83 188223.30 62.31
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Number of Children (Unduplicated) With at Least One Service 849
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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 129 174.50 10140.50 0.00
S 2 2.50 187.50 0.00
H 9 15.00 1025.00 0.00
T 0 0.00 0.00 0.00
0 0.00 0.00 0.00
Other 160 230.50 17046.75 0.00
-------------------------------------------------
Total 300 422.50 28399.75 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 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
1 0.75 27.75 0.00
Other 0 0.00 0.00 0.00
-------------------------------------------------
Total 1 0.75 27.75 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 67 67.00 1086.14 0.00
-------------------------------------------------
Total 67 67.00 1086.14 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 30 31.00 4468.00 7244.91
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 30 31.00 4468.00 7244.91
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
10 10.50 541.50 0.00
Other 0 0.00 0.00 0.00
-------------------------------------------------
Total 10 10.50 541.50 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
347 423.50 21144.58 0.00
Other 0 0.00 0.00 0.00
-------------------------------------------------
Total 347 423.50 21144.58 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
28 31.50 1128.50 0.00
Other 0 0.00 0.00 0.00
-------------------------------------------------
Total 28 31.50 1128.50 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
298 419.75 29215.91 0.00
Other 0 0.00 0.00 0.00
-------------------------------------------------
Total 298 419.75 29215.91 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
250 445.50 31131.00 0.00
Other 0 0.00 0.00 0.00
-------------------------------------------------
Total 250 445.50 31131.00 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
3 4.00 271.52 0.00
Other 0 0.00 0.00 0.00
-------------------------------------------------
Total 3 4.00 271.52 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 0.72 49.00 49.00
D 0 0.00 0.00 0.00
S 0 0.00 0.00 0.00
H 17 52.75 2902.17 0.00
T 0 0.00 0.00 0.00
231 486.00 27566.59 0.00
Other 0 0.00 0.00 0.00
-------------------------------------------------
Total 249 539.47 30517.76 49.00
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
65 104.75 8834.09 0.00
Other 0 0.00 0.00 0.00
-------------------------------------------------
Total 65 104.75 8834.09 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
486 500.00 28560.88 0.00
Other 0 0.00 0.00 0.00
-------------------------------------------------
Total 486 500.00 28560.88 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 7 5.11 558.92 528.92
D 0 0.00 0.00 0.00
S 0 0.00 0.00 0.00
H 8 10.50 2000.00 0.00
T 0 0.00 0.00 0.00
4 5.00 337.00 0.00
Other 0 0.00 0.00 0.00
-------------------------------------------------
Total 19 20.61 2895.92 528.92