CMS/EIP Fiscal Report Statewide
Services beginning 07/01/2008 ending 09/30/2008 Date of Report:11/18/2008 Page: 1
Payclass Filters:GR
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 6701 4719.75 174594.00 36.99
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 4940 5723.00 0.00 0.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 5828 6514.25 240806.25 36.97
TCM-T1017TL-TARGETED CASE MANAGEMENT 9497 28460.8 1051220.50 36.94
TCON-TCON-TRANSITION CONFERENCE 650 662.00 0.00 0.00
Subtotal (Total Children Is Unduplicated) 15528 46079.8 1466620.75 31.83
----------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
ASTE-ASTE-ASSISTIVE TECHNOLOGY EVAL 19 19.00 851.00 44.79
AUDE-92552-PURE TONE AUDIOMETRY -AIR ONLY 19 20.00 211.01 10.55
AUDE-92553-PURE TONE AUDIOMETRY AIR & BONE 6 15.00 229.24 15.28
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 66 78.00 632.89 8.11
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 80 95.00 956.66 10.07
AUDE-92568-ACOUSTIC REFLEX TESTING (MEMR) 8 8.00 67.52 8.44
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 79 82.00 1657.81 20.22
AUDE-92585-AUD EVOKED RESPONSE (DIAG) 3 3.00 163.14 54.38
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 34 35.25 875.93 24.85
AUDE-92588-OTOACOUSTIC EMISSIONS (COMP) 6 6.00 190.86 31.81
AUDE-V5010-ASSESSMENT FOR HEARING AID 1 2.00 93.60 46.80
AUDE-V5090-DISPENSING FEE PER HEARING AID 7 11.00 1071.60 97.42
BEHV-H0031HO-COMP BEHAVIORAL HEALTH ASSESSMENT 16 17.00 1825.00 107.35
EVAL-EVAL-DEVELOPMENTAL EVALUATION 141 165.75 8295.75 50.05
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 2 4.00 222.00 55.50
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 55 77.50 5812.50 75.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 30 40.50 3000.00 74.07
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 17 23.50 1762.50 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 51 67.50 5062.50 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 69 89.50 4967.25 55.50
IPDEI-IPDEI_NM-INITIAL PSYCH & DEV EVAL BY NON-MED PR 78 97.00 5056.00 52.12
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 822 1161.13 86406.46 74.42
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 364 559.00 41887.50 74.93
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 262 346.97 25725.00 74.14
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 1015 1476.50 81849.00 55.43
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 558 783.50 58475.00 74.63
MED-99202-OUTPATIENT VISIT, NEW, 20 MINS 1 1.00 27.22 27.22
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 23 23.00 4255.00 185.00
MED-99204-OUTPATIENT VISIT, NEW, 45 MINS 3 3.00 171.81 57.27
MED-99205-OUTPATIENT VISIT, NEW, 60 MINS 3 5.00 429.19 85.84
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 3 3.00 315.00 105.00
MED-99214-OUTPATIENT VISIT, EST, 25 MINS 1 1.00 160.00 160.00
MED-99215-OUTPATIENT VISIT, EST, 40 MINS 1 1.00 50.15 50.15
NUTR-NUTR-UNSPECIFIED NUTRITIONAL EVAL 1 1.00 50.00 50.00
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 46 45.80 2188.68 47.79
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 93 94.15 4453.91 47.31
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 40 40.00 1874.23 46.86
PSTH-97001-EVAL BY LICENSED PT, INITIAL 59 59.00 2820.00 47.80
SCREEN-T1023-INTERDISCIPLINARY SCREENING 68 68.00 3400.00 50.00
SPCH-92506-SPEECH EVAL BY LICENSED SLP 257 258.00 12290.01 47.64
VISF-VISF-VISION EVALUATION FUNCTIONAL 1 3.00 245.00 81.67
Subtotal (Total Children Is Unduplicated) 2693 6025.55 376697.92 62.52
----------------------------------------------------------------------------------------------------------------
EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 57 189.00 17012.74 90.01
AUD-92630-AUD REHAB PRELING HEARING LOSS 2 9.00 529.09 58.79
AUD-HA_FUP-AUDIOLOGY SERVICES 6 8.00 388.77 48.60
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 653 845.00 41410.00 49.01
COIFP-COIFP-IFSP CONSULT, PRO, BY PHONE 28 17.25 431.25 25.00
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 654 916.25 45677.50 49.85
CONIP-CONIP-CONSULT, ITDS, PHONE 411 778.50 19415.00 24.94
CONOF-CONOF-CONSULT, OT, FACE TO FACE 240 258.25 12673.75 49.08
CONOP-CONOP-CONSULT, OT, PHONE 78 99.75 2447.50 24.54
CONPF-CONPF-CONSULT, PT, FACE TO FACE 153 153.50 7578.75 49.37
CONPP-CONPP-CONSULT, PT, PHONE 22 14.50 362.50 25.00
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 655 860.50 40877.17 47.50
CONSP-CONSP-CONSULT, SLP, PHONE 361 677.00 16757.50 24.75
COUN-H2019HR-INDIVIDUAL/FAMILY THERAPY 21 60.50 3289.31 54.37
ECE-ECE-EARLY CHILDHOOD EDUCATION 1 28.00 252.00 9.00
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 67 872.00 11388.75 13.06
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 70 421.75 21087.50 50.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 2476 17324.1 846665.00 48.87
HERN-EIIF_NM-EI HEARING SERVICES AFTER SHINE NONMED 1 3.00 150.00 50.00
HERN-T1027SC-EI HEARING SERVICES AFTER SHINE 2 2.00 100.00 50.00
INTR-INTR-INTERPRETER 96 405.25 20121.93 49.65
OCCT-97530-OT SESSION BY LICENSED OT 1042 5342.60 348233.50 65.18
OCCT-97530HM-OT SESSION BY OT ASST 54 222.50 9455.35 42.50
CMS/EIP Fiscal Report Statewide
Services beginning 07/01/2008 ending 09/30/2008 Date of Report:11/18/2008 Page: 2
Payclass Filters:GR
Eligibility Filter:Program Patients
List order: No List
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
PHY-97110-PT SESSION BY LICENSED PT 913 4006.43 252138.07 62.93
PHY-97110HM-PT SESSION BY PT ASST 20 79.25 4244.00 53.55
RSPT-RSPT-RESPITE 1 78.00 634.00 8.13
SENS-HA_EIP-ONE UNIT UP TO $500 PER AID 3 5.00 2399.00 479.80
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 5 9.00 1863.60 207.07
SENS-V5264-EARMOLD 11 22.00 379.64 17.26
SHIN-EIIF_NM-INITIAL SHINE SERVICES, IND NONMED 3 5.75 287.50 50.00
SHIN-T1027SC-INITIAL SHINE SERVICES, INDIVIDUAL 9 14.00 700.00 50.00
SIC-SIC-SPECIAL INSTRUCTION CONSULTATION 1 3.00 150.00 50.00
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 2871 17000.7 1134828.67 66.75
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 14 59.50 3222.53 54.16
SPL-92508-GROUP SPL SESSION PER CHILD 3 2.50 33.00 13.20
TRAN-TRAN-FAMILY TRANSPORTATION 378 589.00 14327.85 24.33
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 7876 1670257 888428.97 0.53
VISN-EIIF_NM-EI VISION SERVICES, IND NONMED 15 75.75 4027.50 53.17
Subtotal (Total Children Is Unduplicated) 9675 1722428 3809925.19 2.21
----------------------------------------------------------------------------------------------------------------
Total 1774532.85 5653243.86 3.19
----------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 17712
----------------------------------------------------------------------------------------------------------------
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 4003 115115.50 259933.49 259797.73
D 0 0.00 0.00 0.00
S 485 301.75 11164.75 0.00
H 13 14.50 1019.25 0.00
T 3459 92006.75 198695.70 198695.70
8584 13797.75 198873.71 0.00
Other 420 7487.75 20506.79 0.00
-------------------------------------------------
Total 16964 228724.00 690193.69 458493.43
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 115115.50 259933.49 259797.73
D 0 0.00 0.00 0.00
S 0 301.75 11164.75 0.00
H 0 14.50 1019.25 0.00
T 1082 133626.50 265931.82 265931.82
1610 34576.75 261329.36 678.88
Other 2 7494.75 20659.79 0.00
-------------------------------------------------
Total 2694 291129.75 820038.46 526408.43
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 5478 186145.25 474538.44 474402.68
D 0 0.00 0.00 0.00
S 0 301.75 11164.75 0.00
H 0 14.50 1019.25 0.00
T 3239 136508.75 362452.62 362452.62
27 34591.25 261569.86 678.88
Other 0 7494.75 20659.79 0.00
-------------------------------------------------
Total 8744 365056.25 1131404.71 837534.18
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 3240 307603.78 686058.86 685923.09
D 16 356.00 1015.56 1071.24
S 0 301.75 11164.75 0.00
H 14 48.00 2881.99 1862.74
T 0 136508.75 362452.62 362452.62
5702 38746.75 407985.91 678.88
Other 0 7494.75 20659.79 0.00
-------------------------------------------------
Total 8972 491059.78 1492219.48 1051988.57
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 2648 369561.90 807267.09 807131.32
D 0 356.00 1015.56 1071.24
S 0 301.75 11164.75 0.00
H 0 48.00 2881.99 1862.74
T 0 136508.75 362452.62 362452.62
4871 61626.20 525184.09 678.88
Other 0 7494.75 20659.79 0.00
-------------------------------------------------
Total 7519 575897.35 1730625.89 1173196.80
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 7264 463829.90 1016729.03 1016593.26
D 0 356.00 1015.56 1071.24
S 0 301.75 11164.75 0.00
H 0 48.00 2881.99 1862.74
T 0 136508.75 362452.62 362452.62
14379 161123.20 893870.26 678.88
Other 0 7494.75 20659.79 0.00
-------------------------------------------------
Total 21643 769662.35 2308774.00 1382658.74
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 5681 557951.65 1371742.65 1371606.88
D 0 356.00 1015.56 1071.24
S 10 307.50 11453.50 0.00
H 0 48.00 2881.99 1862.74
T 0 136508.75 362452.62 362452.62
5080 167122.20 1002592.36 678.88
Other 0 7494.75 20659.79 0.00
-------------------------------------------------
Total 10771 869788.85 2772798.47 1737672.36
Center 09
Flag Claims Units Chgs Paid
-------------------------------------------------
R 0 0.00 0.00 0.00
U 0 0.00 0.00 0.00
B 17 13.75 521.75 0.00
P 5171 643775.15 1721104.69 1720968.92
D 0 356.00 1015.56 1071.24
S 0 307.50 11453.50 0.00
H 0 48.00 2881.99 1862.74
T 2737 205422.25 558202.77 558202.77
4972 172349.45 1136370.77 1824.80
Other 0 7494.75 20659.79 0.00
-------------------------------------------------
Total 12897 1029766.85 3452210.82 2283930.47
Center 10
Flag Claims Units Chgs Paid
-------------------------------------------------
R 0 0.00 0.00 0.00
U 0 0.00 0.00 0.00
B 19 23.50 882.50 0.00
P 3748 730624.40 2011193.99 2011058.22
D 22 381.25 2412.81 2468.49
S 0 307.50 11453.50 0.00
H 0 48.00 2881.99 1862.74
T 0 205422.25 558202.77 558202.77
8693 193374.20 1372378.90 1824.80
Other 0 7494.75 20659.79 0.00
-------------------------------------------------
Total 12482 1137675.85 3980066.25 2575417.02
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 23.50 882.50 0.00
P 2019 837400.65 2178650.93 2178515.08
D 70 426.75 4096.31 2468.49
S 0 307.50 11453.50 0.00
H 0 48.00 2881.99 1862.74
T 0 205422.25 558202.77 558202.77
3905 197583.45 1467636.74 1824.80
Other 0 7494.75 20659.79 0.00
-------------------------------------------------
Total 5994 1248706.85 4244464.53 2742873.88
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 23.50 882.50 0.00
P 1 837426.65 2178663.93 2178515.08
D 0 426.75 4096.31 2468.49
S 0 307.50 11453.50 0.00
H 0 48.00 2881.99 1862.74
T 1016 246924.21 614712.65 614606.15
4986 250898.71 1586116.15 1824.80
Other 0 7494.75 20659.79 0.00
-------------------------------------------------
Total 6003 1343550.07 4419466.82 2799277.26
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 23.50 882.50 0.00
P 1325 860027.90 2226339.93 2226191.08
D 0 426.75 4096.31 2468.49
S 0 307.50 11453.50 0.00
H 1526 26404.75 55334.59 54381.90
T 0 246924.21 614712.65 614606.15
1663 279523.17 1661705.89 1824.80
Other 0 7494.75 20659.79 0.00
-------------------------------------------------
Total 4514 1421132.53 4595185.16 2899472.42
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 23.50 882.50 0.00
P 2621 991511.17 2517611.85 2517463.00
D 0 426.75 4096.31 2468.49
S 1 405.50 11689.30 0.00
H 0 26404.75 55334.59 54381.90
T 0 246924.21 614712.65 614606.15
4487 308860.44 1791701.91 1824.80
Other 0 7494.75 20659.79 0.00
-------------------------------------------------
Total 7109 1582051.07 5016688.90 3190744.34
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 23.50 882.50 0.00
P 4490 1042287.70 2661915.05 2661766.20
D 11 437.50 4570.56 2523.99
S 0 405.50 11689.30 0.00
H 0 26404.75 55334.59 54381.90
T 0 246924.21 614712.65 614606.15
1624 310302.44 1832619.41 1824.80
Other 0 7494.75 20659.79 0.00
-------------------------------------------------
Total 6125 1634280.35 5202383.85 3335103.04
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 23.50 882.50 0.00
P 1 1042362.70 2661952.55 2661803.70
D 0 437.50 4570.56 2523.99
S 120 2773.50 18933.84 7244.54
H 0 26404.75 55334.59 54381.90
T 5103 381022.96 942137.59 943191.28
3865 314013.19 1948772.44 2526.62
Other 0 7494.75 20659.79 0.00
-------------------------------------------------
Total 9089 1774532.85 5653243.86 3671672.03