CMS/EIP Fiscal Report Statewide
Services beginning 10/01/2008 ending 12/31/2008 Date of Report:02/17/2009 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 6169 3871.25 143180.75 36.99
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 5393 5999.00 0.00 0.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 5999 6658.00 244793.50 36.77
TCM-T1017TL-TARGETED CASE MANAGEMENT 9579 28863.3 1066500.00 36.95
TCON-TCON-TRANSITION CONFERENCE 907 924.00 0.00 0.00
Subtotal (Total Children Is Unduplicated) 15526 46315.5 1454474.25 31.40
----------------------------------------------------------------------------------------------------------------
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 13 13.00 138.06 10.62
AUDE-92553-PURE TONE AUDIOMETRY AIR & BONE 4 4.00 65.20 16.30
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 43 43.00 379.69 8.83
AUDE-92557-COMP AUDIO THRESHOLD EVAL/SPCH RECOG 2 4.00 90.00 22.50
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 65 65.00 694.22 10.68
AUDE-92568-ACOUSTIC REFLEX TESTING (MEMR) 11 11.00 92.84 8.44
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 70 70.00 1487.25 21.25
AUDE-92585-AUD EVOKED RESPONSE (DIAG) 2 2.00 108.76 54.38
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 33 32.16 864.38 26.88
AUDE-92588-OTOACOUSTIC EMISSIONS (COMP) 9 9.00 286.29 31.81
AUDE-V5090-DISPENSING FEE PER HEARING AID 8 15.00 1279.25 85.28
BEHV-H0031HO-COMP BEHAVIORAL HEALTH ASSESSMENT 17 18.60 1800.00 96.77
EVAL-EVAL-DEVELOPMENTAL EVALUATION 104 122.00 6204.00 50.85
EXIT-EXIT-TRANSITION ASSESSMENT 208 289.00 14450.00 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 68 90.42 6706.50 74.17
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 26 29.92 2244.00 75.00
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 24 28.00 2100.00 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 59 66.00 4875.00 73.86
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 80 102.04 5649.50 55.37
IPDEI-IPDEI_NM-INITIAL PSYCH & DEV EVAL BY NON-MED PR 122 157.50 8402.00 53.35
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 771 1094.21 80968.89 74.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 303 428.27 31894.73 74.47
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 255 334.24 24544.39 73.43
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 882 1258.59 69793.15 55.45
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 526 803.74 59901.58 74.53
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 12 12.00 1642.00 136.83
MED-99204-OUTPATIENT VISIT, NEW, 45 MINS 1 1.00 57.27 57.27
MED-99205-OUTPATIENT VISIT, NEW, 60 MINS 3 3.00 218.34 72.78
MED-99214-OUTPATIENT VISIT, EST, 25 MINS 4 4.00 263.50 65.88
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 37 37.00 1777.90 48.05
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 73 73.56 3522.60 47.89
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 20 19.34 917.67 47.45
PSTH-97001-EVAL BY LICENSED PT, INITIAL 46 46.00 2105.51 45.77
SCREEN-T1023-INTERDISCIPLINARY SCREENING 231 232.00 11600.00 50.00
SPCH-92506-SPEECH EVAL BY LICENSED SLP 283 282.91 13572.38 47.97
VISF-VISF-VISION EVALUATION FUNCTIONAL 3 12.00 840.00 70.00
Subtotal (Total Children Is Unduplicated) 2800 5835.00 362501.10 62.13
----------------------------------------------------------------------------------------------------------------
EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 49 145.00 36743.57 253.40
AUD-92630-AUD REHAB PRELING HEARING LOSS 1 2.00 137.72 68.86
AUD-HA_FUP-AUDIOLOGY SERVICES 3 2.10 105.16 50.08
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 623 791.75 35729.00 45.13
COIFP-COIFP-IFSP CONSULT, PRO, BY PHONE 43 29.00 720.00 24.83
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 783 1322.25 58408.94 44.17
CONIP-CONIP-CONSULT, ITDS, PHONE 348 638.25 15931.25 24.96
CONOF-CONOF-CONSULT, OT, FACE TO FACE 190 225.25 11066.63 49.13
CONOP-CONOP-CONSULT, OT, PHONE 45 46.25 1146.25 24.78
CONPF-CONPF-CONSULT, PT, FACE TO FACE 133 172.25 8425.00 48.91
CONPP-CONPP-CONSULT, PT, PHONE 24 15.00 367.50 24.50
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 684 1028.75 51244.78 49.81
CONSP-CONSP-CONSULT, SLP, PHONE 321 603.25 15062.69 24.97
COUN-H2019HR-INDIVIDUAL/FAMILY THERAPY 9 58.00 2030.00 35.00
EIGF-EIGF_NM-EI GROUP SESSION BY NONMED PROF 8 13.00 370.00 28.46
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 59 345.00 8330.00 24.14
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 51 607.50 30362.50 49.98
EIIF-EIIF_NM-EI INDIVIDUAL SESSION BY NONMED PROF 103 734.42 25553.65 34.79
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 2319 16334.2 797582.93 48.83
HERN-T1027SC-EI HEARING SERVICES AFTER SHINE 4 8.00 400.00 50.00
INTR-INTR-INTERPRETER 103 821.50 22684.00 27.61
OCCT-97530-OT SESSION BY LICENSED OT 980 5201.23 327731.85 63.01
OCCT-97530HM-OT SESSION BY OT ASST 40 155.75 8407.03 53.98
PHY-97110-PT SESSION BY LICENSED PT 850 4322.10 276992.77 64.09
PHY-97110HM-PT SESSION BY PT ASST 21 65.75 3571.54 54.32
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
CMS/EIP Fiscal Report Statewide
Services beginning 10/01/2008 ending 12/31/2008 Date of Report:02/17/2009 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
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 3 5.00 250.00 50.00
SIC-SIC-SPECIAL INSTRUCTION CONSULTATION 1 5.00 250.00 50.00
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 2800 18082.2 1100213.04 60.85
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 17 57.00 3077.23 53.99
SPL-92508-GROUP SPL SESSION PER CHILD 45 204.50 2747.88 13.44
TRAN-TRAN-FAMILY TRANSPORTATION 395 675.00 4027.71 5.97
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 7919 1690419 910068.79 0.54
VISN-EIIF_NM-EI VISION SERVICES, IND NONMED 1 9.00 630.00 70.00
Subtotal (Total Children Is Unduplicated) 9698 1743240 3762581.72 2.16
----------------------------------------------------------------------------------------------------------------
Total 1795390.70 5579557.07 3.11
----------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 17760
----------------------------------------------------------------------------------------------------------------
Center 01
Flag Claims Units Chgs Paid
-------------------------------------------------
R 1 0.25 9.25 0.00
U 0 0.00 0.00 0.00
B 0 0.00 0.00 0.00
P 5092 128618.12 253273.52 253273.52
D 25 35.00 2417.75 0.00
S 110 84.25 3117.25 0.00
H 16 20.50 1274.50 0.00
T 3314 68852.25 147858.24 147830.49
5825 7066.00 135540.65 0.00
Other 87 85.00 5014.66 0.00
-------------------------------------------------
Total 14470 204761.37 548505.82 401104.01
Center 02
Flag Claims Units Chgs Paid
-------------------------------------------------
R 0 0.25 9.25 0.00
U 0 0.00 0.00 0.00
B 0 0.00 0.00 0.00
P 0 128618.12 253273.52 253273.52
D 0 35.00 2417.75 0.00
S 0 84.25 3117.25 0.00
H 0 20.50 1274.50 0.00
T 736 93723.25 184789.57 184761.82
2116 44176.75 221998.40 0.00
Other 0 85.00 5014.66 0.00
-------------------------------------------------
Total 2852 266743.12 671894.90 438035.34
Center 03
Flag Claims Units Chgs Paid
-------------------------------------------------
R 0 0.25 9.25 0.00
U 0 0.00 0.00 0.00
B 0 0.00 0.00 0.00
P 3832 178599.87 413804.98 413804.98
D 0 35.00 2417.75 0.00
S 0 84.25 3117.25 0.00
H 0 20.50 1274.50 0.00
T 3409 96500.00 270113.85 270067.60
1856 67680.75 294279.80 0.00
Other 0 85.00 5014.66 0.00
-------------------------------------------------
Total 9097 343005.62 990032.04 683872.58
Center 04
Flag Claims Units Chgs Paid
-------------------------------------------------
R 15 15.75 582.75 0.00
U 0 0.00 0.00 0.00
B 0 0.00 0.00 0.00
P 2250 276048.79 565673.66 565825.19
D 126 360.25 8439.64 6021.89
S 0 84.25 3117.25 0.00
H 27 99.00 5530.28 4357.60
T 0 96500.00 270113.85 270067.60
5131 71626.75 428450.30 0.00
Other 0 85.00 5014.66 0.00
-------------------------------------------------
Total 7549 444819.79 1286922.39 846272.28
Center 05
Flag Claims Units Chgs Paid
-------------------------------------------------
R 0 15.75 582.75 0.00
U 0 0.00 0.00 0.00
B 0 0.00 0.00 0.00
P 3028 360573.82 713108.50 713260.03
D 0 360.25 8439.64 6021.89
S 0 84.25 3117.25 0.00
H 0 99.00 5530.28 4357.60
T 0 96500.00 270113.85 270067.60
3642 75882.77 497332.44 0.00
Other 0 85.00 5014.66 0.00
-------------------------------------------------
Total 6670 533600.84 1503239.37 993707.12
Center 06
Flag Claims Units Chgs Paid
-------------------------------------------------
R 0 15.75 582.75 0.00
U 0 0.00 0.00 0.00
B 0 0.00 0.00 0.00
P 7624 431810.57 919073.33 919224.86
D 0 360.25 8439.64 6021.89
S 0 84.25 3117.25 0.00
H 0 99.00 5530.28 4357.60
T 0 96500.00 270113.85 270067.60
13622 195915.52 849713.04 0.00
Other 0 85.00 5014.66 0.00
-------------------------------------------------
Total 21246 724870.34 2061584.80 1199671.95
Center 07
Flag Claims Units Chgs Paid
-------------------------------------------------
R 0 15.75 582.75 0.00
U 0 0.00 0.00 0.00
B 1 0.50 18.50 0.00
P 7516 531740.36 1336151.17 1338485.70
D 66 405.25 10389.64 6021.89
S 2 85.25 3154.25 0.00
H 0 99.00 5530.28 4357.60
T 0 96500.00 270113.85 270067.60
2918 199426.77 918072.61 0.00
Other 0 85.00 5014.66 0.00
-------------------------------------------------
Total 10503 828357.88 2549027.71 1618932.79
Center 09
Flag Claims Units Chgs Paid
-------------------------------------------------
R 0 15.75 582.75 0.00
U 0 0.00 0.00 0.00
B 0 0.50 18.50 0.00
P 13129 689625.11 1991030.77 1993315.30
D 0 405.25 10389.64 6021.89
S 0 85.25 3154.25 0.00
H 0 99.00 5530.28 4357.60
T 0 96500.00 270113.85 270067.60
610 204006.27 964595.06 1643.63
Other 0 85.00 5014.66 0.00
-------------------------------------------------
Total 13739 990822.13 3250429.76 2275406.02
Center 10
Flag Claims Units Chgs Paid
-------------------------------------------------
R 0 15.75 582.75 0.00
U 0 0.00 0.00 0.00
B 0 0.50 18.50 0.00
P 3646 775874.86 2293798.47 2296083.00
D 103 463.00 12526.39 8112.39
S 0 85.25 3154.25 0.00
H 0 99.00 5530.28 4357.60
T 0 96500.00 270113.85 270067.60
8792 216425.02 1194030.81 1643.63
Other 0 85.00 5014.66 0.00
-------------------------------------------------
Total 12541 1089548.38 3784769.96 2580264.22
Center 51
Flag Claims Units Chgs Paid
-------------------------------------------------
R 0 15.75 582.75 0.00
U 0 0.00 0.00 0.00
B 0 0.50 18.50 0.00
P 1989 888490.61 2454432.06 2456716.59
D 24 476.75 13042.14 8112.39
S 0 85.25 3154.25 0.00
H 0 99.00 5530.28 4357.60
T 0 96500.00 270113.85 270067.60
3725 219984.52 1288450.61 1648.63
Other 0 85.00 5014.66 0.00
-------------------------------------------------
Total 5738 1205737.38 4040339.10 2740902.81
Center 52
Flag Claims Units Chgs Paid
-------------------------------------------------
R 0 15.75 582.75 0.00
U 0 0.00 0.00 0.00
B 1 0.75 27.75 0.00
P 2 888491.11 2454450.56 2456735.09
D 0 476.75 13042.14 8112.39
S 0 85.25 3154.25 0.00
H 0 99.00 5530.28 4357.60
T 0 96500.00 270113.85 270067.60
6077 327259.44 1477088.50 1648.63
Other 0 85.00 5014.66 0.00
-------------------------------------------------
Total 6080 1313013.05 4229004.74 2740921.31
Center 53
Flag Claims Units Chgs Paid
-------------------------------------------------
R 0 15.75 582.75 0.00
U 0 0.00 0.00 0.00
B 0 0.75 27.75 0.00
P 0 888491.11 2454450.56 2456735.09
D 1 477.25 13060.64 8112.39
S 0 85.25 3154.25 0.00
H 2016 33704.15 72305.53 71307.85
T 1594 123150.50 323668.07 323621.82
1849 358251.75 1536613.51 1648.63
Other 0 85.00 5014.66 0.00
-------------------------------------------------
Total 5460 1404261.51 4408877.72 2861425.78
Center 54
Flag Claims Units Chgs Paid
-------------------------------------------------
R 0 15.75 582.75 0.00
U 0 0.00 0.00 0.00
B 0 0.75 27.75 0.00
P 3064 1035373.00 2777786.41 2780070.94
D 19 490.50 13550.89 8112.39
S 0 85.25 3154.25 0.00
H 0 33704.15 72305.53 71307.85
T 0 123150.50 323668.07 323621.82
5067 390318.50 1675368.61 1648.63
Other 0 85.00 5014.66 0.00
-------------------------------------------------
Total 8150 1583223.40 4871458.92 3184761.63
Center 55
Flag Claims Units Chgs Paid
-------------------------------------------------
R 0 15.75 582.75 0.00
U 0 0.00 0.00 0.00
B 0 0.75 27.75 0.00
P 4887 1093762.30 2929801.86 2932086.39
D 21 506.50 14199.89 8112.39
S 0 85.25 3154.25 0.00
H 0 33704.15 72305.53 71307.85
T 0 123150.50 323668.07 323621.82
1684 391808.00 1718310.36 1648.63
Other 0 85.00 5014.66 0.00
-------------------------------------------------
Total 6592 1643118.20 5067065.12 3336777.08
Center 57
Flag Claims Units Chgs Paid
-------------------------------------------------
R 0 15.75 582.75 0.00
U 0 0.00 0.00 0.00
B 0 0.75 27.75 0.00
P 0 1093762.30 2929801.86 2932086.39
D 0 506.50 14199.89 8112.39
S 229 5361.75 16699.39 13545.14
H 0 33704.15 72305.53 71307.85
T 5561 265802.25 685354.13 686550.88
4330 396152.25 1855571.11 1851.13
Other 0 85.00 5014.66 0.00
-------------------------------------------------
Total 10120 1795390.70 5579557.07 3713453.78