CMS/EIP Fiscal Report Statewide
Services beginning 07/01/2010 ending 09/30/2010 Date of Report:11/17/2010 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 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 3 32.000000 1184.0000 37.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 32 49.500000 1831.5000 37.0000
TCON-TCON-TRANSITION CONFERENCE 1 1.000000 0.0000 0.0000
Subtotal (Total Children Is Unduplicated) 43 101.750000 3061.7500 30.0909
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Screening, Eval, and Assessment,Class #02
AUDE-92552-PURE TONE AUDIOMETRY -AIR ONLY 10 10.000000 107.9100 10.7910
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 75 76.000000 740.3600 9.7416
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 60 62.000000 702.6000 11.3323
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 74 76.000000 1684.3600 22.1626
AUDE-92585-AUD EVOKED RESPONSE (DIAG) 1 1.000000 49.7300 49.7300
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 8 8.000000 210.3100 26.2888
AUDE-92588-OTOACOUSTIC EMISSIONS (COMP) 9 9.000000 393.2900 43.6989
BEHV-H0031HO-COMP BEHAVIORAL HEALTH ASSESSMENT 4 6.000000 750.0000 125.0000
EVAL-EVAL-DEVELOPMENTAL EVALUATION 3 6.500000 325.0000 50.0000
EXIT-EXIT-TRANSITION ASSESSMENT 14 27.000000 1400.0000 51.8519
IPDEF-IPDEF_NM-F/U PSYCH & DEV EVAL BY NON-MED PROF 1 1.000000 55.5000 55.5000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 60 102.321600 7674.3700 75.0024
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 9 14.000000 1050.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 11 14.000000 1050.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 39 69.000000 5312.5000 76.9928
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 28 48.500000 2691.7500 55.5000
IPDEI-IPDEI_NM-INITIAL PSYCH & DEV EVAL BY NON-MED PR 4 5.198190 288.4995 55.4999
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 489 770.364966 58502.0000 75.9406
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 177 262.175100 19663.0700 74.9998
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 179 268.021160 20185.2470 75.3121
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 352 579.072602 33415.8094 57.7057
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 251 376.392267 31174.0400 82.8233
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 3 3.000000 150.4500 50.1500
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 1 1.000000 48.5000 48.5000
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 52 50.392160 2444.0997 48.5015
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 3 1.500000 81.2300 54.1533
PSTH-97001-EVAL BY LICENSED PT, INITIAL 37 35.500000 1722.5000 48.5211
SCREEN-T1023-INTERDISCIPLINARY SCREENING 6 6.000000 300.0000 50.0000
SENS-V5014TS-HEARING AID REPAIR IN-OFFICE 1 1.000000 29.7600 29.7600
SPCH-92506-SPEECH EVAL BY LICENSED SLP 108 114.920000 6358.9000 55.3333
Subtotal (Total Children Is Unduplicated) 1092 3014.858045 199232.1656 66.0834
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 10 47.000000 11431.4400 243.2221
AUD-HA_FUP-AUDIOLOGY SERVICES 3 5.000000 166.3800 33.2760
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 11 17.000000 850.0000 50.0000
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 7 6.250000 312.5000 50.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 2 1.500000 75.0000 50.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 7 4.500000 225.0000 50.0000
CONPP-CONPP-CONSULT, PT, PHONE 1 0.250000 6.2500 25.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 7 7.750000 387.5000 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 176 705.080000 35274.7700 50.0295
HERN-T1027SC-EI HEARING SERVICES AFTER SHINE 2 17.000000 850.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 529 2268.610190 156992.2390 69.2019
OCCT-97530HM-OT SESSION BY OT ASST 38 124.193769 6768.2500 54.4975
PHY-97110-PT SESSION BY LICENSED PT 610 2689.104695 180305.3097 67.0503
PHY-97110HM-PT SESSION BY PT ASST 16 56.000000 3041.9200 54.3200
SENS-V5014-HEARING AID REPAIR BY MANUFACTURER 1 5.000000 211.5300 42.3060
SENS-V5264-EARMOLD 2 2.000000 36.0000 18.0000
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 1061 4595.425547 316025.1500 68.7695
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 25 85.500000 4644.3600 54.3200
SPL-92508-GROUP SPL SESSION PER CHILD 17 44.250000 584.1000 13.2000
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 14 1377.000000 652.3000 0.4737
Subtotal (Total Children Is Unduplicated) 1836 12081.66420 719708.7487 59.5703
-----------------------------------------------------------------------------------------------------------------------
Total 15198.272246 922002.6643 60.6650
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 2672
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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 4 4.500000 317.8800 281.2500
D 153 196.500000 12072.5000 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
841 868.990000 59468.8500 0.0000
Other 671 660.250000 45541.1600 2875.0000
---------------------------------------------------------
Total 1686 1758.240000 119462.8900 3156.2500
Center 02
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
14 24.000000 1770.7500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 14 24.000000 1770.7500 0.0000
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
6 6.000000 407.2800 0.0000
Other 51 51.000000 783.6600 0.0000
---------------------------------------------------------
Total 57 57.000000 1190.9400 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 7 26.000000 1300.0000 1300.0000
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 181 467.000000 30956.9200 30732.8200
---------------------------------------------------------
Total 189 494.000000 32441.9200 32032.8200
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
358 253.619720 14412.1000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 358 253.619720 14412.1000 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 20 12.500000 848.5000 848.5000
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
1553 1286.750000 86138.3500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 1573 1299.250000 86986.8500 848.5000
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 34 125.500000 7571.3000 7571.3000
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
187 782.750000 25232.2700 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 221 908.250000 32803.5700 7571.3000
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 36 27.750000 1883.6700 2174.9900
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
1558 2360.750000 160639.4200 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 1594 2388.500000 162523.0900 2174.9900
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
1468 2478.500000 166132.8200 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 1468 2478.500000 166132.8200 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 38 311.500000 5358.2600 5358.2200
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
141 286.250000 22961.5700 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 179 597.750000 28319.8300 5358.2200
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 4 9.000000 575.1600 575.1600
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
551 1164.448226 73761.0023 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 562 1188.948226 75298.6623 575.1600
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 10 12.053285 781.7159 781.7200
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
523 475.960510 34065.7497 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 533 488.013795 34847.4656 781.7200
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
761 1775.080000 69902.2464 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 761 1775.080000 69902.2464 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 15 22.000000 3750.0000 0.0000
T 0 0.000000 0.0000 0.0000
968 719.120505 48259.3700 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 984 742.620505 52259.3700 205.0000
Center 57
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 7 7.500000 489.7200 489.7200
D 0 0.000000 0.0000 0.0000
S 3 3.000000 184.2600 184.2600
H 0 0.000000 0.0000 0.0000
T 6 8.000000 454.9000 454.9000
319 724.000000 42392.3000 32855.1600
Other 2 2.000000 128.9800 128.9800
---------------------------------------------------------
Total 337 744.500000 43650.1600 34113.0200