CMS/EIP Fiscal Report Statewide
Services beginning 07/01/2010 ending 09/30/2010 Date of Report:11/17/2010 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
CASE-CASE-NON-TCM CASE MANAGEMENT 2 1.250000 46.2500 37.0000
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 9 18.000000 0.0000 0.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 2 2.000000 74.0000 37.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 23 44.000000 1628.0000 37.0000
TCON-TCON-TRANSITION CONFERENCE 1 1.000000 0.0000 0.0000
Subtotal (Total Children Is Unduplicated) 33 66.250000 1748.2500 26.3887
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Screening, Eval, and Assessment,Class #02
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 51 52.000000 458.2800 8.8131
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 36 37.000000 399.6000 10.8000
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 49 50.000000 1090.0200 21.8004
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 4 4.000000 113.1200 28.2800
BEHV-H0031HO-COMP BEHAVIORAL HEALTH ASSESSMENT 3 5.000000 625.0000 125.0000
EXIT-EXIT-TRANSITION ASSESSMENT 9 18.250000 912.5000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 43 75.500000 5662.5000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 6 10.000000 750.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 7 9.000000 675.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 32 56.500000 4375.0000 77.4336
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 18 30.500000 1692.7500 55.5000
IPDEI-IPDEI_NM-INITIAL PSYCH & DEV EVAL BY NON-MED PR 1 1.198190 66.4995 55.4995
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 233 376.136800 28572.2400 75.9624
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 100 157.000000 11775.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 74 118.861160 8914.5870 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 203 347.691161 19935.4994 57.3368
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 153 240.392267 20282.7200 84.3734
MED-99202-OUTPATIENT VISIT, NEW, 20 MINS 1 1.000000 27.2200 27.2200
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 1 1.000000 185.0000 185.0000
MED-99204-OUTPATIENT VISIT, NEW, 45 MINS 8 8.000000 458.1600 57.2700
MED-99215-OUTPATIENT VISIT, EST, 40 MINS 2 2.000000 100.3000 50.1500
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 5 5.000000 242.5000 48.5000
PSTH-97001-EVAL BY LICENSED PT, INITIAL 4 4.000000 194.0000 48.5000
SCREEN-T1023-INTERDISCIPLINARY SCREENING 4 4.000000 200.0000 50.0000
SPCH-92506-SPEECH EVAL BY LICENSED SLP 11 12.000000 1314.5800 109.5483
Subtotal (Total Children Is Unduplicated) 537 1626.029578 109022.0759 67.0480
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 4 10.000000 500.0000 50.0000
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 4 3.250000 162.5000 50.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 5 3.500000 175.0000 50.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 2 3.000000 150.0000 50.0000
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 2 11.750000 293.7500 25.0000
EIIF-EIIF_NM-EI INDIVIDUAL SESSION BY NONMED PROF 1 11.500000 575.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 69 291.500000 14612.5000 50.1286
HERN-T1027SC-EI HEARING SERVICES AFTER SHINE 1 7.000000 350.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 14 57.250000 3886.1300 67.8800
PHY-97110-PT SESSION BY LICENSED PT 19 69.250000 4700.6900 67.8800
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 49 275.250000 18683.9700 67.8800
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 1 1.000000 0.5000 0.5000
Subtotal (Total Children Is Unduplicated) 152 744.250000 44090.0400 59.2409
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Total 2436.529578 154860.3659 63.5578
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Number of Children (Unduplicated) With at Least One Service 687
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Center 01
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 0 0.000000 0.0000 0.0000
P 2 2.000000 137.5000 187.5000
D 95 127.500000 7755.5000 0.0000
S 7 10.500000 787.5000 0.0000
H 10 17.500000 1275.0000 0.0000
T 0 0.000000 0.0000 0.0000
0 0.000000 0.0000 0.0000
Other 105 147.000000 10925.0000 2125.0000
---------------------------------------------------------
Total 219 304.500000 20880.5000 2312.5000
Center 03
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 0 0.000000 0.0000 0.0000
P 0 0.000000 0.0000 0.0000
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
0 0.000000 0.0000 0.0000
Other 47 47.000000 722.6000 0.0000
---------------------------------------------------------
Total 47 47.000000 722.6000 0.0000
Center 04
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 0 0.000000 0.0000 0.0000
P 0 0.000000 0.0000 0.0000
D 1 1.000000 185.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
0 0.000000 0.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 1 1.000000 185.0000 0.0000
Center 05
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 0 0.000000 0.0000 0.0000
P 0 0.000000 0.0000 0.0000
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
6 5.750000 372.6500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 6 5.750000 372.6500 0.0000
Center 06
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 0 0.000000 0.0000 0.0000
P 0 0.000000 0.0000 0.0000
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
257 336.000000 18300.5500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 257 336.000000 18300.5500 0.0000
Center 07
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 0 0.000000 0.0000 0.0000
P 0 0.000000 0.0000 0.0000
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
29 39.000000 1073.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 29 39.000000 1073.0000 0.0000
Center 09
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 0 0.000000 0.0000 0.0000
P 0 0.000000 0.0000 0.0000
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
249 372.750000 25238.1400 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 249 372.750000 25238.1400 0.0000
Center 10
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 0 0.000000 0.0000 0.0000
P 0 0.000000 0.0000 0.0000
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
195 355.000000 24723.7500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 195 355.000000 24723.7500 0.0000
Center 51
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 0 0.000000 0.0000 0.0000
P 0 0.000000 0.0000 0.0000
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
6 6.000000 407.2800 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 6 6.000000 407.2800 0.0000
Center 52
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 0 0.000000 0.0000 0.0000
P 0 0.000000 0.0000 0.0000
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 7 15.500000 962.5000 0.0000
T 0 0.000000 0.0000 0.0000
205 448.750000 27551.8100 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 212 464.250000 28514.3100 0.0000
Center 53
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 0 0.000000 0.0000 0.0000
P 8 8.779578 572.8759 572.8800
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
28 43.000000 4946.5000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 36 51.779578 5519.3759 572.8800
Center 54
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 0 0.000000 0.0000 0.0000
P 0 0.000000 0.0000 0.0000
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
392 424.500000 25150.7100 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 392 424.500000 25150.7100 0.0000
Center 55
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 0 0.000000 0.0000 0.0000
P 1 1.500000 250.0000 205.0000
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 12 18.000000 3000.0000 0.0000
T 0 0.000000 0.0000 0.0000
8 9.500000 522.5000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 21 29.000000 3772.5000 205.0000