CMS/EIP Fiscal Report Statewide
Services beginning 10/01/2008 ending 12/31/2008 Date of Report:02/17/2009 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 6172 3874.75 143310.25 36.99
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 5403 6009.00 0.00 0.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 6005 6665.00 245052.50 36.77
TCM-T1017TL-TARGETED CASE MANAGEMENT 18834 58751.8 2170952.00 36.95
TCON-TCON-TRANSITION CONFERENCE 908 925.00 0.00 0.00
Subtotal (Total Children Is Unduplicated) 19261 76225.5 2559314.75 33.58
----------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
ASTE-ASTE-ASSISTIVE TECHNOLOGY EVAL 8 8.00 364.50 45.56
AUDE-92552-PURE TONE AUDIOMETRY -AIR ONLY 30 30.00 318.60 10.62
AUDE-92553-PURE TONE AUDIOMETRY AIR & BONE 10 10.00 163.00 16.30
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 231 233.00 2109.56 9.05
AUDE-92557-COMP AUDIO THRESHOLD EVAL/SPCH RECOG 2 4.00 90.00 22.50
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 233 235.00 2561.42 10.90
AUDE-92568-ACOUSTIC REFLEX TESTING (MEMR) 24 24.00 202.56 8.44
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 257 258.00 5611.98 21.75
AUDE-92585-AUD EVOKED RESPONSE (DIAG) 6 7.00 380.66 54.38
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 42 42.00 1143.06 27.22
AUDE-92588-OTOACOUSTIC EMISSIONS (COMP) 31 32.00 1017.92 31.81
AUDE-V5090-DISPENSING FEE PER HEARING AID 8 15.00 1279.25 85.28
BEHV-H0031HO-COMP BEHAVIORAL HEALTH ASSESSMENT 20 23.60 2350.00 99.58
EVAL-EVAL-DEVELOPMENTAL EVALUATION 119 149.00 7704.00 51.70
EXIT-EXIT-TRANSITION ASSESSMENT 210 291.00 14550.00 50.00
FANE-FANE-FAMILY INTERVIEW BY COMMUNITY PROVIDER 4 5.00 150.00 30.00
IPDEF-IPDEF_NM-F/U PSYCH & DEV EVAL BY NON-MED PROF 8 8.50 449.75 52.91
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 211 296.50 21965.00 74.08
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 80 112.00 8347.00 74.53
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 96 119.50 8883.00 74.33
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 156 221.00 17065.63 77.22
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 199 263.50 15027.25 57.03
IPDEI-IPDEI_NM-INITIAL PSYCH & DEV EVAL BY NON-MED PR 130 174.00 9275.75 53.31
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 2129 3034.38 224131.04 73.86
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 845 1300.00 97163.26 74.74
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 834 1143.49 84939.95 74.28
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 1887 2735.50 151838.86 55.51
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 1276 2024.00 153515.65 75.85
MED-99202-OUTPATIENT VISIT, NEW, 20 MINS 6 6.00 163.32 27.22
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 130 130.00 23327.50 179.44
MED-99204-OUTPATIENT VISIT, NEW, 45 MINS 24 24.00 2027.67 84.49
MED-99205-OUTPATIENT VISIT, NEW, 60 MINS 13 13.00 946.14 72.78
MED-99212-OUTPATIENT VISIT, EST, 10 MINS 2 2.00 36.34 18.17
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 46 46.00 4830.00 105.00
MED-99214-OUTPATIENT VISIT, EST, 25 MINS 10 10.00 596.00 59.60
MED-99215-OUTPATIENT VISIT, EST, 40 MINS 9 9.00 451.35 50.15
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 79 80.00 3863.40 48.29
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 168 172.00 8571.50 49.83
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 65 69.00 3326.17 48.21
PSTH-97001-EVAL BY LICENSED PT, INITIAL 109 110.00 5188.24 47.17
SCREEN-T1023-INTERDISCIPLINARY SCREENING 355 359.00 17950.00 50.00
SPCH-92506-SPEECH EVAL BY LICENSED SLP 438 442.00 21258.52 48.10
VISF-VISF-VISION EVALUATION FUNCTIONAL 3 12.00 840.00 70.00
Subtotal (Total Children Is Unduplicated) 5379 14283.0 925974.80 64.83
----------------------------------------------------------------------------------------------------------------
EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 54 179.00 51145.49 285.73
AUD-92630-AUD REHAB PRELING HEARING LOSS 1 2.00 137.72 68.86
AUD-HA_FUP-AUDIOLOGY SERVICES 4 4.00 200.00 50.00
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 629 803.25 36284.00 45.17
COIFP-COIFP-IFSP CONSULT, PRO, BY PHONE 43 29.00 720.00 24.83
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 787 1327.00 58646.44 44.19
CONIP-CONIP-CONSULT, ITDS, PHONE 350 643.25 16056.25 24.96
CONOF-CONOF-CONSULT, OT, FACE TO FACE 193 229.75 11291.63 49.15
CONOP-CONOP-CONSULT, OT, PHONE 45 46.25 1146.25 24.78
CONPF-CONPF-CONSULT, PT, FACE TO FACE 136 175.50 8587.50 48.93
CONPP-CONPP-CONSULT, PT, PHONE 24 15.00 367.50 24.50
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 700 1053.25 52469.78 49.82
CONSP-CONSP-CONSULT, SLP, PHONE 323 603.75 15075.19 24.97
COUN-H2019HR-INDIVIDUAL/FAMILY THERAPY 12 71.00 2961.04 41.70
ECE-ECE-EARLY CHILDHOOD EDUCATION 114 18840.0 169560.00 9.00
EIGF-EIGF_NM-EI GROUP SESSION BY NONMED PROF 114 3831.00 95820.00 25.01
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 145 2617.25 65136.25 24.89
EIIF-90801-PSYCHIATRIC DIAG INTERVIEW 1 8.00 400.00 50.00
EIIF-90812-INDIVIDUAL PSYCHOTHERAPY, 45-50 MINUTES 1 5.00 271.55 54.31
EIIF-96154-HEALTH AND BEHAVIOR INTERVENTION 52 612.00 30587.50 49.98
EIIF-EIIF_NM-EI INDIVIDUAL SESSION BY NONMED PROF 172 1403.67 54466.15 38.80
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 4333 29925.2 1477395.21 49.37
HERN-T1027SC-EI HEARING SERVICES AFTER SHINE 8 22.00 1100.00 50.00
INTR-INTR-INTERPRETER 103 821.50 22684.00 27.61
OCCT-97530-OT SESSION BY LICENSED OT 1901 10447.7 685186.46 65.58
CMS/EIP Fiscal Report Statewide
Services beginning 10/01/2008 ending 12/31/2008 Date of Report:02/17/2009 Page: 2
Eligibility Filter:Program Patients
List order: No List
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
OCCT-97530HM-OT SESSION BY OT ASST 95 340.50 18442.65 54.16
PHY-97110-PT SESSION BY LICENSED PT 1932 10046.6 666145.70 66.31
PHY-97110HM-PT SESSION BY PT ASST 74 331.50 18013.82 54.34
RSPT-RSPT-RESPITE 1 65.00 520.00 8.00
SENS-HA_INS-SENSORY AID INSURANCE PER EAR 1 1.00 65.00 65.00
SENS-V5014-HEARING AID REPAIR BY MANUFACTURER 1 2.00 228.00 114.00
SENS-V5050-MED HEARING AID - ANALOG/DIGITAL 1 2.00 456.00 228.00
SENS-V5264-EARMOLD 6 12.00 221.76 18.48
SHIN-EIIF_NM-INITIAL SHINE SERVICES, IND NONMED 1 1.00 50.00 50.00
SHIN-T1027SC-INITIAL SHINE SERVICES, INDIVIDUAL 8 16.00 800.00 50.00
SIC-SIC-SPECIAL INSTRUCTION CONSULTATION 1 5.00 250.00 50.00
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 4460 26903.1 1700257.85 63.20
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 32 97.50 5277.19 54.13
SPL-92508-GROUP SPL SESSION PER CHILD 64 246.75 3305.58 13.40
TRAN-TRAN-FAMILY TRANSPORTATION 427 1817.00 110068.71 60.58
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 7963 1695638 915082.94 0.54
VISN-EIIF_NM-EI VISION SERVICES, IND NONMED 7 52.00 2780.00 53.46
Subtotal (Total Children Is Unduplicated) 10658 1809292 6299661.11 3.48
----------------------------------------------------------------------------------------------------------------
Total 1899800.74 9784950.66 5.15
----------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 20489
----------------------------------------------------------------------------------------------------------------
Center 01
Flag Claims Units Chgs Paid
-------------------------------------------------
R 1 0.25 9.25 0.00
U 0 0.00 0.00 0.00
B 911 636.25 23541.25 0.00
P 5096 128623.12 253495.52 253273.52
D 229 205.75 8748.50 0.00
S 614 491.00 18167.00 0.00
H 52 71.00 4568.13 0.00
T 3320 68860.75 148419.78 148373.53
6708 8941.80 241942.99 0.00
Other 2874 1976.75 84668.95 0.00
-------------------------------------------------
Total 19805 209806.67 783561.37 401647.05
Center 02
Flag Claims Units Chgs Paid
-------------------------------------------------
R 16 13.50 499.50 0.00
U 0 0.00 0.00 0.00
B 777 1207.75 44622.00 0.00
P 0 128623.12 253495.52 253273.52
D 0 205.75 8748.50 0.00
S 0 491.00 18167.00 0.00
H 0 71.00 4568.13 0.00
T 736 93731.75 185351.11 185304.86
2317 46309.05 341934.74 0.00
Other 0 1976.75 84668.95 0.00
-------------------------------------------------
Total 3846 272629.67 942055.45 438578.38
Center 03
Flag Claims Units Chgs Paid
-------------------------------------------------
R 11 19.00 703.00 0.00
U 0 0.00 0.00 0.00
B 540 1659.25 63718.50 9.25
P 4798 179406.37 444603.73 444368.73
D 0 205.75 8748.50 0.00
S 1 491.50 18185.50 0.00
H 1 71.25 4577.38 9.25
T 3409 96508.50 270675.39 270610.64
1897 69843.55 415401.64 0.00
Other 156 2132.25 86971.79 18.50
-------------------------------------------------
Total 10813 350337.42 1313585.43 715016.37
Center 04
Flag Claims Units Chgs Paid
-------------------------------------------------
R 27 57.00 2109.00 0.00
U 0 0.00 0.00 0.00
B 2983 4546.50 175441.25 9.25
P 3371 277867.04 636621.31 636321.52
D 128 532.75 14848.14 6049.64
S 0 491.50 18185.50 0.00
H 791 2600.53 134438.62 129780.63
T 0 96508.50 270675.39 270610.64
6313 81216.80 806851.65 0.00
Other 0 2132.25 86971.79 18.50
-------------------------------------------------
Total 13613 465952.87 2146142.65 1042790.18
Center 05
Flag Claims Units Chgs Paid
-------------------------------------------------
R 20 77.00 3473.20 0.00
U 0 0.00 0.00 0.00
B 2209 5708.25 218521.00 9.25
P 3028 362392.07 784056.15 783756.36
D 0 532.75 14848.14 6049.64
S 0 491.50 18185.50 0.00
H 0 2600.53 134438.62 129780.63
T 0 96508.50 270675.39 270610.64
6502 87747.32 1011261.48 0.00
Other 0 2132.25 86971.79 18.50
-------------------------------------------------
Total 11759 558190.17 2542431.27 1190225.02
Center 06
Flag Claims Units Chgs Paid
-------------------------------------------------
R 0 77.00 3473.20 0.00
U 0 0.00 0.00 0.00
B 2623 7421.00 281871.00 92.50
P 7624 433628.82 990020.98 989721.19
D 0 532.75 14848.14 6049.64
S 0 491.50 18185.50 0.00
H 0 2600.53 134438.62 129780.63
T 0 96508.50 270675.39 270610.64
19152 212516.82 1651255.31 0.00
Other 0 2132.25 86971.79 18.50
-------------------------------------------------
Total 29399 755909.17 3451739.93 1396273.10
Center 07
Flag Claims Units Chgs Paid
-------------------------------------------------
R 1 77.50 3491.70 0.00
U 0 0.00 0.00 0.00
B 2100 8951.25 343839.00 92.50
P 8767 534879.86 1450703.60 1452571.56
D 68 578.75 16835.14 6049.64
S 168 628.00 24202.00 0.00
H 0 2600.53 134438.62 129780.63
T 0 96508.50 270675.39 270610.64
3678 217903.07 1820073.73 0.00
Other 0 2132.25 86971.79 18.50
-------------------------------------------------
Total 14782 864259.71 4151230.97 1859123.47
Center 09
Flag Claims Units Chgs Paid
-------------------------------------------------
R 7 86.00 3919.20 0.00
U 0 0.00 0.00 0.00
B 582 9539.50 375481.34 120.25
P 15961 695345.11 2221988.31 2223816.94
D 0 578.75 16835.14 6049.64
S 0 628.00 24202.00 0.00
H 1 2601.28 134466.37 129808.38
T 0 96508.50 270675.39 270610.64
3516 227713.07 2187055.78 1643.63
Other 0 2132.25 86971.79 18.50
-------------------------------------------------
Total 20067 1035132.46 5321595.32 2632067.98
Center 10
Flag Claims Units Chgs Paid
-------------------------------------------------
R 5 87.75 3983.95 0.00
U 0 0.00 0.00 0.00
B 6561 13720.00 531226.84 120.25
P 4260 782494.61 2587970.76 2589840.14
D 121 646.75 19351.14 8519.39
S 168 731.75 28040.75 0.00
H 0 2601.28 134466.37 129808.38
T 0 96508.50 270675.39 270610.64
10363 243087.82 2605129.64 1643.63
Other 0 2132.25 86971.79 18.50
-------------------------------------------------
Total 21478 1142010.71 6267816.63 3000560.93
Center 51
Flag Claims Units Chgs Paid
-------------------------------------------------
R 2 89.75 4133.95 0.00
U 0 0.00 0.00 0.00
B 3196 15971.00 616173.14 120.25
P 2017 895332.61 2752938.27 2754807.65
D 24 660.50 19866.89 8519.39
S 0 731.75 28040.75 0.00
H 0 2601.28 134466.37 129808.38
T 0 96508.50 270675.39 270610.64
4810 249380.57 2866261.77 1648.63
Other 0 2132.25 86971.79 18.50
-------------------------------------------------
Total 10049 1263408.21 6779528.32 3165533.44
Center 52
Flag Claims Units Chgs Paid
-------------------------------------------------
R 8 97.75 4668.29 0.00
U 0 0.00 0.00 0.00
B 1352 16822.75 651609.31 129.50
P 856 895907.20 2780007.58 2781876.96
D 0 660.50 19866.89 8519.39
S 3 741.25 28392.25 0.00
H 95 2775.03 145339.14 129808.38
T 0 96508.50 270675.39 270610.64
7638 361784.24 3237973.85 1648.63
Other 0 2132.25 86971.79 18.50
-------------------------------------------------
Total 9952 1377429.47 7225504.49 3192612.00
Center 53
Flag Claims Units Chgs Paid
-------------------------------------------------
R 136 255.50 10505.04 9.25
U 0 0.00 0.00 0.00
B 64 16880.00 653844.56 274.75
P 1273 897188.89 2845514.49 2847092.62
D 345 975.25 34211.28 8519.39
S 4 746.25 28660.50 0.00
H 2016 36380.18 212114.39 196758.63
T 1594 123159.00 324229.61 324164.86
3708 394667.90 3393865.65 2220.15
Other 39 2195.25 91925.79 18.50
-------------------------------------------------
Total 9179 1472448.22 7594871.31 3379058.15
Center 54
Flag Claims Units Chgs Paid
-------------------------------------------------
R 15 266.00 10884.29 9.25
U 0 0.00 0.00 0.00
B 1143 17585.75 680044.06 274.75
P 5357 1045598.03 3230310.50 3266025.19
D 21 989.00 34720.03 8519.39
S 0 746.25 28660.50 0.00
H 0 36380.18 212114.39 196758.63
T 0 123159.00 324229.61 324164.86
6811 429769.95 3712601.20 2220.15
Other 0 2195.25 91925.79 18.50
-------------------------------------------------
Total 13347 1656689.41 8325490.37 3797990.72
Center 55
Flag Claims Units Chgs Paid
-------------------------------------------------
R 31 304.75 12318.04 9.25
U 0 0.00 0.00 0.00
B 14 17605.25 681449.56 274.75
P 5871 1104953.33 3419506.22 3455220.91
D 21 1005.00 35369.03 8519.39
S 11 760.50 29187.75 0.00
H 0 36380.18 212114.39 196758.63
T 0 123159.00 324229.61 324164.86
4026 433179.73 3878454.55 2220.15
Other 1 2195.75 91944.29 18.50
-------------------------------------------------
Total 9975 1719543.49 8684573.44 3987186.44
Center 57
Flag Claims Units Chgs Paid
-------------------------------------------------
R 136 462.25 18145.54 9.25
U 0 0.00 0.00 0.00
B 1092 18683.50 721326.31 274.75
P 652 1105575.83 3442538.72 3478253.31
D 10 1015.75 35766.78 8519.39
S 239 6208.50 43863.39 14620.14
H 0 36380.18 212114.39 196758.63
T 5575 265853.75 688154.07 689332.32
6510 463272.23 4528205.25 137355.92
Other 38 2348.75 94836.21 2891.92
-------------------------------------------------
Total 14252 1899800.74 9784950.66 4528015.63