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:Program Patients
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 2 1.50 55.50 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 22 76.00 2802.75 36.88
Subtotal (Total Children Is Unduplicated) 29 83.50 2858.25 34.23
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Screening, Eval, and Assessment,Class #02
AUDE-92552-PURE TONE AUDIOMETRY -AIR ONLY 50 50.00 531.00 10.62
AUDE-92553-PURE TONE AUDIOMETRY AIR & BONE 1 1.00 16.30 16.30
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 149 151.00 1320.75 8.75
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 126 130.00 1396.30 10.74
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 147 151.00 3295.23 21.82
AUDE-92585-AUD EVOKED RESPONSE (DIAG) 5 5.00 271.90 54.38
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 40 41.00 1159.48 28.28
AUDE-92588-OTOACOUSTIC EMISSIONS (COMP) 8 9.00 286.29 31.81
EVAL-EVAL-DEVELOPMENTAL EVALUATION 1 4.00 200.00 50.00
EXIT-EXIT-TRANSITION ASSESSMENT 5 8.00 400.00 50.00
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 71 115.14 8635.50 75.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 18 31.18 2339.36 75.03
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 3 3.50 262.50 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 47 79.18 5901.86 74.54
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 42 65.00 3607.50 55.50
IPDEI-IPDEI_NM-INITIAL PSYCH & DEV EVAL BY NON-MED PR 6 12.00 976.28 81.36
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 619 919.73 68355.31 74.32
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 230 367.23 28086.35 76.48
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 162 232.83 17615.89 75.66
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 432 671.50 38664.51 57.58
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 259 392.58 31820.89 81.06
MED-99202-OUTPATIENT VISIT, NEW, 20 MINS 4 4.00 108.88 27.22
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 22 22.00 4070.00 185.00
MED-99204-OUTPATIENT VISIT, NEW, 45 MINS 12 12.00 687.24 57.27
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 2 2.00 210.00 105.00
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 2 2.00 97.00 48.50
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 59 63.00 3055.50 48.50
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 3 2.00 126.78 63.39
PSTH-97001-EVAL BY LICENSED PT, INITIAL 27 26.28 1275.37 48.53
SCREEN-T1023-INTERDISCIPLINARY SCREENING 2 2.00 100.00 50.00
SENS-V5014TS-HEARING AID REPAIR IN-OFFICE 1 4.00 60.00 15.00
SPCH-92506-SPEECH EVAL BY LICENSED SLP 151 165.20 8089.44 48.97
Subtotal (Total Children Is Unduplicated) 1333 3744.35 233023.41 62.23
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 5 27.00 7324.65 271.28
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 5 7.25 362.50 50.00
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 9 7.50 375.00 50.00
CONOF-CONOF-CONSULT, OT, FACE TO FACE 4 4.00 200.00 50.00
CONPF-CONPF-CONSULT, PT, FACE TO FACE 7 5.50 275.00 50.00
CONPP-CONPP-CONSULT, PT, PHONE 2 0.75 18.75 25.00
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 10 9.25 462.50 50.00
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 4 12.00 300.00 25.00
EIIF-96154-HEALTH AND BEHAVIOR INTERVENTION 1 2.00 100.00 50.00
EIIF-EIIF_NM-EI INDIVIDUAL SESSION BY NONMED PROF 2 45.75 2287.50 50.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 167 797.00 39828.90 49.97
HERN-T1027SC-EI HEARING SERVICES AFTER SHINE 2 13.00 650.00 50.00
INTR-INTR-INTERPRETER 1 5.00 250.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 564 2577.02 176435.23 68.46
OCCT-97530HM-OT SESSION BY OT ASST 27 110.03 6342.89 57.65
PHY-97110-PT SESSION BY LICENSED PT 616 2834.86 194381.77 68.57
PHY-97110HM-PT SESSION BY PT ASST 15 52.82 2869.68 54.33
SENS-V5264-EARMOLD 1 2.00 37.44 18.72
SHIN-T1027SC-INITIAL SHINE SERVICES, INDIVIDUAL 1 1.00 50.00 50.00
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 1139 4923.58 337183.64 68.48
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 15 53.50 2906.12 54.32
SPL-92508-GROUP SPL SESSION PER CHILD 12 27.50 363.00 13.20
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 12 1283.00 846.10 0.66
Subtotal (Total Children Is Unduplicated) 1892 12801.3 773850.67 60.45
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Total 16629.16 1009732.33 60.72
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Number of Children (Unduplicated) With at Least One Service 2917
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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 5 5.00 339.40 0.00
D 187 248.00 14446.63 0.00
S 4 5.50 412.50 0.00
H 13 20.50 1437.50 0.00
T 0 0.00 0.00 0.00
667 470.25 45456.52 237.58
Other 991 1024.25 69568.82 0.00
-------------------------------------------------
Total 1867 1773.50 131661.37 237.58
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
6 9.75 610.75 0.00
Other 0 0.00 0.00 0.00
-------------------------------------------------
Total 6 9.75 610.75 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
21 21.00 1126.68 0.00
Other 84 84.00 1343.87 0.00
-------------------------------------------------
Total 105 105.00 2470.55 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 35 36.00 5043.50 8398.40
D 0 0.00 0.00 0.00
S 0 0.00 0.00 0.00
H 258 545.50 35901.50 35602.74
T 0 0.00 0.00 0.00
0 0.00 0.00 0.00
Other 0 0.00 0.00 0.00
-------------------------------------------------
Total 293 581.50 40945.00 44001.14
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
211 187.24 7338.68 0.00
Other 0 0.00 0.00 0.00
-------------------------------------------------
Total 211 187.24 7338.68 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 2 1.00 67.88 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
1843 1546.50 95968.53 0.00
Other 0 0.00 0.00 0.00
-------------------------------------------------
Total 1845 1547.50 96036.41 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 57 224.25 12724.83 12724.83
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
210 552.25 28504.42 0.00
Other 0 0.00 0.00 0.00
-------------------------------------------------
Total 267 776.50 41229.25 12724.83
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 35 25.25 1728.21 3313.12
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
1782 2663.75 181788.85 193.73
Other 0 0.00 0.00 0.00
-------------------------------------------------
Total 1817 2689.00 183517.06 3506.85
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
1832 2976.50 187441.93 0.00
Other 0 0.00 0.00 0.00
-------------------------------------------------
Total 1832 2976.50 187441.93 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 44 86.00 5379.90 5379.90
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
222 446.25 28840.73 0.00
Other 0 0.00 0.00 0.00
-------------------------------------------------
Total 266 532.25 34220.63 5379.90
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 2 2.22 132.25 49.00
D 0 0.00 0.00 0.00
S 0 0.00 0.00 0.00
H 18 53.75 2957.67 0.00
T 0 0.00 0.00 0.00
682 1497.78 93998.54 0.00
Other 0 0.00 0.00 0.00
-------------------------------------------------
Total 702 1553.75 97088.46 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
768 684.75 43932.27 0.00
Other 0 0.00 0.00 0.00
-------------------------------------------------
Total 768 684.75 43932.27 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
680 1796.47 47202.80 0.00
Other 0 0.00 0.00 0.00
-------------------------------------------------
Total 680 1796.47 47202.80 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 9 8.11 733.92 703.92
D 0 0.00 0.00 0.00
S 0 0.00 0.00 0.00
H 9 11.50 2250.00 0.00
T 0 0.00 0.00 0.00
853 603.12 40193.08 0.00
Other 0 0.00 0.00 0.00
-------------------------------------------------
Total 871 622.73 43177.00 703.92
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 3 1.72 116.71 116.72
D 0 0.00 0.00 0.00
S 1 1.00 67.88 67.88
H 0 0.00 0.00 0.00
T 1 1.50 101.82 101.82
385 788.50 52573.76 41271.74
Other 0 0.00 0.00 0.00
-------------------------------------------------
Total 390 792.72 52860.17 41558.16