CMS/EIP Fiscal Report Statewide
Services beginning 07/01/2008 ending 09/30/2008 Date of Report:11/18/2008 Page: 1
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 6713 4726.75 174853.00 36.99
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 4946 5732.00 262.50 0.05
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 5857 6545.25 241953.25 36.97
TCM-T1017TL-TARGETED CASE MANAGEMENT 18640 58155.8 2148050.50 36.94
TCON-TCON-TRANSITION CONFERENCE 650 662.00 0.00 0.00
Subtotal (Total Children Is Unduplicated) 19097 75821.8 2565119.25 33.83
----------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
ASTE-ASTE-ASSISTIVE TECHNOLOGY EVAL 19 19.00 851.00 44.79
AUD-92626-EVAL OF AUD REHAB STATUS 1 1.00 36.07 36.07
AUDE-92552-PURE TONE AUDIOMETRY -AIR ONLY 24 25.00 264.11 10.56
AUDE-92553-PURE TONE AUDIOMETRY AIR & BONE 7 16.00 245.54 15.35
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 353 366.00 3175.93 8.68
AUDE-92557-COMP AUDIO THRESHOLD EVAL/SPCH RECOG 1 1.00 27.10 27.10
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 329 347.00 3677.42 10.60
AUDE-92568-ACOUSTIC REFLEX TESTING (MEMR) 12 12.00 101.28 8.44
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 351 356.00 7628.27 21.43
AUDE-92585-AUD EVOKED RESPONSE (DIAG) 5 5.00 271.90 54.38
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 68 69.25 1837.45 26.53
AUDE-92588-OTOACOUSTIC EMISSIONS (COMP) 18 18.00 572.58 31.81
AUDE-V5010-ASSESSMENT FOR HEARING AID 1 2.00 93.60 46.80
AUDE-V5090-DISPENSING FEE PER HEARING AID 9 16.00 1669.60 104.35
BEHV-H0031HO-COMP BEHAVIORAL HEALTH ASSESSMENT 17 18.00 1875.00 104.17
EVAL-EVAL-DEVELOPMENTAL EVALUATION 159 192.75 9645.75 50.04
EXIT-EXIT-TRANSITION ASSESSMENT 101 127.00 6350.00 50.00
FANE-FANE-FAMILY INTERVIEW BY COMMUNITY PROVIDER 9 9.00 270.00 30.00
IPDEF-IPDEF_NM-F/U PSYCH & DEV EVAL BY NON-MED PROF 5 9.00 499.50 55.50
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 214 302.50 22650.00 74.88
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 61 83.50 6412.50 76.80
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 90 110.50 8287.50 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 169 253.00 19312.50 76.33
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 199 283.00 15694.75 55.46
IPDEI-IPDEI_NM-INITIAL PSYCH & DEV EVAL BY NON-MED PR 89 117.50 6179.75 52.59
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 1923 2715.75 201299.50 74.12
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 804 1250.00 94067.50 75.25
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 811 1071.58 79476.50 74.17
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 2068 3042.00 168620.25 55.43
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 1238 1743.00 130937.50 75.12
MED-99202-OUTPATIENT VISIT, NEW, 20 MINS 9 9.00 244.98 27.22
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 155 155.00 28530.50 184.07
MED-99204-OUTPATIENT VISIT, NEW, 45 MINS 41 41.00 3654.45 89.13
MED-99205-OUTPATIENT VISIT, NEW, 60 MINS 18 20.00 1520.89 76.04
MED-99212-OUTPATIENT VISIT, EST, 10 MINS 1 1.00 18.17 18.17
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 34 34.00 3570.00 105.00
MED-99214-OUTPATIENT VISIT, EST, 25 MINS 3 3.00 229.00 76.33
MED-99215-OUTPATIENT VISIT, EST, 40 MINS 10 10.00 501.50 50.15
NUTR-NUTR-UNSPECIFIED NUTRITIONAL EVAL 1 1.00 50.00 50.00
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 90 90.00 4332.68 48.14
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 180 191.00 9407.55 49.25
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 95 106.00 5075.23 47.88
PSTH-97001-EVAL BY LICENSED PT, INITIAL 136 137.00 6603.00 48.20
SCREEN-T1023-INTERDISCIPLINARY SCREENING 144 144.00 7200.00 50.00
SPCH-92506-SPEECH EVAL BY LICENSED SLP 450 455.00 22200.88 48.79
VISF-VISF-VISION EVALUATION FUNCTIONAL 1 3.00 245.00 81.67
Subtotal (Total Children Is Unduplicated) 5165 13981.3 885414.18 63.33
----------------------------------------------------------------------------------------------------------------
EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 59 206.00 18573.31 90.16
AUD-92630-AUD REHAB PRELING HEARING LOSS 2 9.00 529.09 58.79
AUD-HA_FUP-AUDIOLOGY SERVICES 7 9.00 438.77 48.75
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 656 849.50 41635.00 49.01
COIFP-COIFP-IFSP CONSULT, PRO, BY PHONE 28 17.25 431.25 25.00
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 657 918.00 45765.00 49.85
CONIP-CONIP-CONSULT, ITDS, PHONE 412 778.75 19421.25 24.94
CONOF-CONOF-CONSULT, OT, FACE TO FACE 242 260.75 12798.75 49.08
CONOP-CONOP-CONSULT, OT, PHONE 78 99.75 2447.50 24.54
CONPF-CONPF-CONSULT, PT, FACE TO FACE 156 157.00 7743.75 49.32
CONPP-CONPP-CONSULT, PT, PHONE 22 14.50 362.50 25.00
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 663 875.75 41639.67 47.55
CONSP-CONSP-CONSULT, SLP, PHONE 362 678.00 16782.50 24.75
COUN-H2019HR-INDIVIDUAL/FAMILY THERAPY 23 73.50 4243.77 57.74
ECE-ECE-EARLY CHILDHOOD EDUCATION 102 9228.00 83052.00 9.00
EIGF-EIGF_NM-EI GROUP SESSION BY NONMED PROF 108 3232.00 80800.00 25.00
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 149 2908.00 62283.75 21.42
EIIF-90801-PSYCHIATRIC DIAG INTERVIEW 1 5.00 250.00 50.00
EIIF-96154-HEALTH AND BEHAVIOR INTERVENTION 76 701.00 35050.00 50.00
EIIF-EIIF_NM-EI INDIVIDUAL SESSION BY NONMED PROF 125 748.00 33580.00 44.89
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 4397 30515.0 1509745.53 49.48
HERN-EIIF_NM-EI HEARING SERVICES AFTER SHINE NONMED 1 3.00 150.00 50.00
CMS/EIP Fiscal Report Statewide
Services beginning 07/01/2008 ending 09/30/2008 Date of Report:11/18/2008 Page: 2
Eligibility Filter:Program Patients
List order: No List
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
HERN-T1027SC-EI HEARING SERVICES AFTER SHINE 5 10.00 500.00 50.00
INTR-INTR-INTERPRETER 96 405.25 20121.93 49.65
OCCT-97530-OT SESSION BY LICENSED OT 2035 11047.7 740789.07 67.05
OCCT-97530HM-OT SESSION BY OT ASST 140 542.75 26957.69 49.67
PHY-97110-PT SESSION BY LICENSED PT 2127 10193.5 673133.73 66.04
PHY-97110HM-PT SESSION BY PT ASST 76 379.69 20565.16 54.16
RSPT-RSPT-RESPITE 1 78.00 634.00 8.13
SENS-HA_EIP-ONE UNIT UP TO $500 PER AID 4 7.00 3399.00 485.57
SENS-HA_INS-SENSORY AID INSURANCE PER EAR 1 2.00 86.00 43.00
SENS-V5014-HEARING AID REPAIR BY MANUFACTURER 2 5.00 570.00 114.00
SENS-V5050-MED HEARING AID - ANALOG/DIGITAL 6 11.00 2337.84 212.53
SENS-V5264-EARMOLD 14 31.00 548.12 17.68
SHIN-EIIF_NM-INITIAL SHINE SERVICES, IND NONMED 3 5.75 287.50 50.00
SHIN-T1027SC-INITIAL SHINE SERVICES, INDIVIDUAL 13 19.50 975.00 50.00
SIC-SIC-SPECIAL INSTRUCTION CONSULTATION 1 3.00 150.00 50.00
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 4527 25997.1 1746349.13 67.17
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 40 132.50 7187.89 54.25
SPL-92508-GROUP SPL SESSION PER CHILD 41 90.25 1278.10 14.16
TRAN-TRAN-FAMILY TRANSPORTATION 406 1789.00 134327.85 75.09
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 7881 1672933 889744.70 0.53
VISN-EIIF_NM-EI VISION SERVICES, IND NONMED 41 233.75 11927.50 51.03
Subtotal (Total Children Is Unduplicated) 10637 1776203 6299593.60 3.55
----------------------------------------------------------------------------------------------------------------
Total 1866006.56 9750127.03 5.23
----------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 20460
----------------------------------------------------------------------------------------------------------------
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 4007 115127.75 262021.22 261727.21
D 0 0.00 0.00 0.00
S 1577 997.00 36916.75 0.00
H 49 58.00 3846.50 0.00
T 3640 92241.25 214148.12 214148.12
9911 16238.00 338381.28 0.00
Other 5024 10533.75 140270.54 0.00
-------------------------------------------------
Total 24208 235195.75 995584.41 475875.33
Center 02
Flag Claims Units Chgs Paid
-------------------------------------------------
R 34 21.50 795.50 0.00
U 0 0.00 0.00 0.00
B 953 793.25 29285.50 0.00
P 0 115127.75 262021.22 261727.21
D 0 0.00 0.00 0.00
S 0 997.00 36916.75 0.00
H 0 58.00 3846.50 0.00
T 1082 133861.00 281384.24 281384.24
1774 37222.00 410830.18 678.88
Other 2 10540.75 140423.54 0.00
-------------------------------------------------
Total 3845 298621.25 1165503.43 543790.33
Center 03
Flag Claims Units Chgs Paid
-------------------------------------------------
R 4 24.50 906.50 0.00
U 0 0.00 0.00 0.00
B 224 1020.00 40168.25 0.00
P 6478 186959.75 506385.42 506033.91
D 0 0.00 0.00 0.00
S 0 997.00 36916.75 0.00
H 0 58.00 3846.50 0.00
T 3239 136743.25 377905.04 377905.04
63 37271.75 412792.93 678.88
Other 138 10678.75 142534.75 0.00
-------------------------------------------------
Total 10146 373753.00 1521456.14 884617.83
Center 04
Flag Claims Units Chgs Paid
-------------------------------------------------
R 22 73.00 2701.00 0.00
U 0 0.00 0.00 0.00
B 4206 5067.25 191207.00 0.00
P 3407 308572.78 731013.35 730688.32
D 69 420.50 5068.06 2509.14
S 0 997.00 36916.75 0.00
H 1010 3368.87 173320.66 169951.08
T 0 136743.25 377905.04 377905.04
6755 47742.75 773690.76 678.88
Other 0 10678.75 142534.75 0.00
-------------------------------------------------
Total 15469 513664.15 2434357.37 1281732.46
Center 05
Flag Claims Units Chgs Paid
-------------------------------------------------
R 32 105.00 4661.06 0.00
U 0 0.00 0.00 0.00
B 2315 6324.25 237716.00 0.00
P 2648 370530.90 852221.58 851896.55
D 0 420.50 5068.06 2509.14
S 0 997.00 36916.75 0.00
H 0 3368.87 173320.66 169951.08
T 0 136743.25 377905.04 377905.04
8641 72918.20 1038331.27 678.88
Other 0 10678.75 142534.75 0.00
-------------------------------------------------
Total 13636 602086.72 2868675.17 1402940.69
Center 06
Flag Claims Units Chgs Paid
-------------------------------------------------
R 1 105.50 4679.56 0.00
U 0 0.00 0.00 0.00
B 2972 8264.75 309514.50 0.00
P 7264 464798.90 1061683.52 1061358.49
D 0 420.50 5068.06 2509.14
S 0 997.00 36916.75 0.00
H 0 3368.87 173320.66 169951.08
T 0 136743.25 377905.04 377905.04
19964 177184.45 1684665.84 678.88
Other 0 10678.75 142534.75 0.00
-------------------------------------------------
Total 30201 802561.97 3796288.68 1612402.63
Center 07
Flag Claims Units Chgs Paid
-------------------------------------------------
R 2 106.50 4716.56 0.00
U 0 0.00 0.00 0.00
B 3035 10242.75 383380.50 0.00
P 5787 559119.15 1430753.14 1430428.11
D 0 420.50 5068.06 2509.14
S 228 1149.75 42829.50 0.00
H 0 3368.87 173320.66 169951.08
T 0 136743.25 377905.04 377905.04
5736 185006.95 1878695.18 678.88
Other 0 10678.75 142534.75 0.00
-------------------------------------------------
Total 14788 906836.47 4439203.39 1981472.25
Center 09
Flag Claims Units Chgs Paid
-------------------------------------------------
R 23 124.25 5790.11 0.00
U 0 0.00 0.00 0.00
B 570 10816.75 415444.08 152.75
P 7945 647575.15 1899634.36 1929086.17
D 0 420.50 5068.06 2509.14
S 0 1149.75 42829.50 0.00
H 1 3370.62 173385.41 170015.83
T 2737 205656.75 573655.19 573655.19
7876 195455.45 2352339.79 3762.80
Other 2 10680.00 142581.00 0.00
-------------------------------------------------
Total 19154 1075249.22 5610727.50 2679181.88
Center 10
Flag Claims Units Chgs Paid
-------------------------------------------------
R 2 126.00 5854.86 0.00
U 0 0.00 0.00 0.00
B 6940 15399.50 586938.08 152.75
P 4509 735479.90 2259426.73 2288829.47
D 114 525.25 10203.81 7644.89
S 0 1149.75 42829.50 0.00
H 0 3370.62 173385.41 170015.83
T 0 205656.75 573655.19 573655.19
10889 220337.70 2838222.41 3762.80
Other 0 10680.00 142581.00 0.00
-------------------------------------------------
Total 22454 1192725.47 6633096.99 3044060.93
Center 51
Flag Claims Units Chgs Paid
-------------------------------------------------
R 0 126.00 5854.86 0.00
U 0 0.00 0.00 0.00
B 3137 17467.25 665085.59 152.75
P 2024 842386.15 2428027.78 2457362.56
D 70 570.75 11887.31 7644.89
S 0 1149.75 42829.50 0.00
H 1 3372.62 173535.41 170015.83
T 1 205657.25 573673.69 573655.19
4897 226997.20 3077112.79 3762.80
Other 0 10680.00 142581.00 0.00
-------------------------------------------------
Total 10130 1308406.97 7120587.93 3212594.02
Center 52
Flag Claims Units Chgs Paid
-------------------------------------------------
R 0 126.00 5854.86 0.00
U 0 0.00 0.00 0.00
B 1848 18611.25 714173.26 152.75
P 143 842486.15 2430840.54 2460026.56
D 0 570.75 11887.31 7644.89
S 1 1150.00 42838.75 0.00
H 79 3496.87 181497.49 170015.83
T 1016 247159.21 630183.57 630058.57
6434 284559.24 3371621.63 3762.80
Other 0 10680.00 142581.00 0.00
-------------------------------------------------
Total 9521 1408839.47 7531478.41 3271661.40
Center 53
Flag Claims Units Chgs Paid
-------------------------------------------------
R 64 154.75 6983.61 50.00
U 0 0.00 0.00 0.00
B 500 18989.25 729235.39 162.00
P 1435 865197.40 2483916.54 2513102.56
D 0 570.75 11887.31 7644.89
S 0 1150.00 42838.75 0.00
H 1528 29855.62 234050.09 222634.99
T 0 247159.21 630183.57 630058.57
3472 315042.99 3541404.21 4209.80
Other 4 10684.00 142797.84 0.00
-------------------------------------------------
Total 7003 1488803.97 7823297.31 3377862.81
Center 54
Flag Claims Units Chgs Paid
-------------------------------------------------
R 0 154.75 6983.61 50.00
U 0 0.00 0.00 0.00
B 2253 20550.75 789014.39 162.00
P 3443 997256.17 2799993.06 2827278.80
D 0 570.75 11887.31 7644.89
S 2 1249.00 43310.35 0.00
H 0 29855.62 234050.09 222634.99
T 0 247159.21 630183.57 630058.57
6202 347552.24 3860300.62 4209.80
Other 0 10684.00 142797.84 0.00
-------------------------------------------------
Total 11900 1655032.49 8518520.84 3692039.05
Center 55
Flag Claims Units Chgs Paid
-------------------------------------------------
R 0 154.75 6983.61 50.00
U 0 0.00 0.00 0.00
B 139 20718.00 795715.64 162.00
P 5343 1048894.20 2976818.76 3004104.50
D 11 581.50 12361.56 7700.39
S 11 1261.75 43782.10 0.00
H 0 29855.62 234050.09 222634.99
T 0 247159.21 630183.57 630058.57
3837 350690.28 4012088.28 4209.80
Other 0 10684.00 142797.84 0.00
-------------------------------------------------
Total 9341 1709999.31 8854781.45 3868920.25
Center 57
Flag Claims Units Chgs Paid
-------------------------------------------------
R 0 154.75 6983.61 50.00
U 0 0.00 0.00 0.00
B 1095 21763.00 834393.64 180.50
P 426 1049362.95 2991425.01 3018692.25
D 0 581.50 12361.56 7700.39
S 128 3656.75 52376.64 8594.54
H 0 29855.62 234050.09 222634.99
T 5125 381385.96 961038.51 962073.70
5483 368192.53 4513362.39 130924.89
Other 12 11053.50 144135.58 1337.74
-------------------------------------------------
Total 12269 1866006.56 9750127.03 4352189.00