CMS/EIP Fiscal Report Statewide
Services beginning 01/01/2009 ending 03/31/2009 Date of Report:05/18/2009 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 6692 4181.00 154604.50 36.98
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 5697 6250.00 0.00 0.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 6286 6832.25 252617.50 36.97
TCM-T1017TL-TARGETED CASE MANAGEMENT 19480 63305.0 2339715.75 36.96
TCON-TCON-TRANSITION CONFERENCE 1145 1155.00 0.00 0.00
Subtotal (Total Children Is Unduplicated) 19955 81723.3 2746937.75 33.61
----------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
ASTE-ASTE-ASSISTIVE TECHNOLOGY EVAL 12 12.00 535.00 44.58
AUD-92626-EVAL OF AUD REHAB STATUS 1 1.00 36.07 36.07
AUDE-92552-PURE TONE AUDIOMETRY -AIR ONLY 27 28.00 297.36 10.62
AUDE-92553-PURE TONE AUDIOMETRY AIR & BONE 12 12.00 193.84 16.15
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 271 275.00 2427.35 8.83
AUDE-92557-COMP AUDIO THRESHOLD EVAL/SPCH RECOG 2 3.00 72.10 24.03
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 257 269.00 2896.38 10.77
AUDE-92568-ACOUSTIC REFLEX TESTING (MEMR) 25 26.00 219.44 8.44
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 294 300.79 6549.30 21.77
AUDE-92585-AUD EVOKED RESPONSE (DIAG) 2 2.00 108.76 54.38
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 36 38.00 1074.64 28.28
AUDE-92588-OTOACOUSTIC EMISSIONS (COMP) 36 37.00 1176.97 31.81
AUDE-V5010-ASSESSMENT FOR HEARING AID 1 1.00 46.80 46.80
AUDE-V5090-DISPENSING FEE PER HEARING AID 6 11.00 1210.40 110.04
BEHV-90801-PSYCHIATRIC DIAG INTERVIEW 1 1.00 50.00 50.00
BEHV-H0031HO-COMP BEHAVIORAL HEALTH ASSESSMENT 11 11.00 925.00 84.09
EVAL-EVAL-DEVELOPMENTAL EVALUATION 102 127.50 6502.50 51.00
EXIT-EXIT-TRANSITION ASSESSMENT 263 398.25 20437.50 51.32
IPDEF-IPDEF_NM-F/U PSYCH & DEV EVAL BY NON-MED PROF 7 8.50 455.25 53.56
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 209 307.50 22896.86 74.46
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 80 121.00 9543.76 78.87
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 77 102.00 7623.50 74.74
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 153 224.50 17053.13 75.96
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 205 304.50 16888.75 55.46
IPDEI-IPDEI_NM-INITIAL PSYCH & DEV EVAL BY NON-MED PR 71 92.00 4886.25 53.11
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 2293 3293.19 245334.40 74.50
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 869 1377.50 103016.38 74.79
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 737 985.86 73202.18 74.25
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 2250 3451.50 191287.63 55.42
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 1459 2311.50 174637.54 75.55
MED-99202-OUTPATIENT VISIT, NEW, 20 MINS 6 6.00 271.10 45.18
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 160 162.00 28091.50 173.40
MED-99204-OUTPATIENT VISIT, NEW, 45 MINS 27 27.00 2417.21 89.53
MED-99205-OUTPATIENT VISIT, NEW, 60 MINS 21 21.00 1528.38 72.78
MED-99212-OUTPATIENT VISIT, EST, 10 MINS 1 1.00 18.17 18.17
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 52 52.00 5460.00 105.00
MED-99214-OUTPATIENT VISIT, EST, 25 MINS 3 3.00 480.00 160.00
MED-99215-OUTPATIENT VISIT, EST, 40 MINS 9 9.00 451.35 50.15
NUTR-97802-NUTRITIONAL EVAL, INITIAL 1 1.00 50.00 50.00
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 92 93.00 4389.87 47.20
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 203 212.66 10286.60 48.37
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 63 63.00 3014.79 47.85
PSTH-97001-EVAL BY LICENSED PT, INITIAL 143 152.25 7193.27 47.25
SCREEN-T1023-INTERDISCIPLINARY SCREENING 281 283.00 14150.00 50.00
SPCH-92506-SPEECH EVAL BY LICENSED SLP 472 478.00 23098.80 48.32
VISD-VISD-VISION EVALUATION DIAGNOSTIC 1 40.00 20.00 0.50
VISF-VISF-VISION EVALUATION FUNCTIONAL 4 7.00 490.00 70.00
Subtotal (Total Children Is Unduplicated) 5717 15744.0 1012996.08 64.34
----------------------------------------------------------------------------------------------------------------
EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 48 120.00 23906.75 199.22
AUD-92630-AUD REHAB PRELING HEARING LOSS 2 6.00 413.16 68.86
AUD-HA_FUP-AUDIOLOGY SERVICES 9 11.00 524.69 47.70
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 722 898.00 41222.30 45.90
COIFP-COIFP-IFSP CONSULT, PRO, BY PHONE 49 30.00 720.00 24.00
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 914 1495.00 69867.50 46.73
CONIP-CONIP-CONSULT, ITDS, PHONE 315 523.00 13052.50 24.96
CONOF-CONOF-CONSULT, OT, FACE TO FACE 255 288.00 14320.16 49.72
CONOP-CONOP-CONSULT, OT, PHONE 42 44.00 1095.00 24.89
CONPF-CONPF-CONSULT, PT, FACE TO FACE 187 233.00 11524.13 49.46
CONPP-CONPP-CONSULT, PT, PHONE 31 19.50 470.75 24.14
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 864 1384.50 67601.33 48.83
CONSP-CONSP-CONSULT, SLP, PHONE 288 504.50 12555.00 24.89
COUN-H2019HR-INDIVIDUAL/FAMILY THERAPY 10 48.00 1540.00 32.08
ECE-ECE-EARLY CHILDHOOD EDUCATION 89 14195.0 133002.00 9.37
EIGF-EIGF_NM-EI GROUP SESSION BY NONMED PROF 97 2805.50 69307.50 24.70
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 133 2863.75 61518.75 21.48
EIIF-90801-PSYCHIATRIC DIAG INTERVIEW 1 4.00 200.00 50.00
EIIF-96154-HEALTH AND BEHAVIOR INTERVENTION 31 434.25 21712.50 50.00
EIIF-EIIF_NM-EI INDIVIDUAL SESSION BY NONMED PROF 274 1599.24 62713.49 39.21
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 4551 32180.9 1584057.31 49.22
CMS/EIP Fiscal Report Statewide
Services beginning 01/01/2009 ending 03/31/2009 Date of Report:05/18/2009 Page: 2
Eligibility Filter:Program Patients
List order: No List
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
HERN-EIIF_NM-EI HEARING SERVICES AFTER SHINE NONMED 8 20.50 1025.00 50.00
HERN-T1027SC-EI HEARING SERVICES AFTER SHINE 8 32.50 1625.00 50.00
INTR-INTR-INTERPRETER 128 802.00 29620.25 36.93
OCCT-97530-OT SESSION BY LICENSED OT 1979 10698.9 708425.60 66.21
OCCT-97530HM-OT SESSION BY OT ASST 116 490.25 26202.12 53.45
PHY-97110-PT SESSION BY LICENSED PT 1934 10075.0 677213.25 67.22
PHY-97110HM-PT SESSION BY PT ASST 80 306.00 16785.09 54.85
RSPT-RSPT-RESPITE 1 53.00 424.00 8.00
SENS-FM-FM RECEIVER HEARING AID 2 2.00 2989.75 1494.88
SENS-HA_EIP-ONE UNIT UP TO $500 PER AID 1 2.00 1000.00 500.00
SENS-V5050-MED HEARING AID - ANALOG/DIGITAL 3 6.00 1386.24 231.04
SENS-V5264-EARMOLD 15 29.00 535.00 18.45
SHIN-T1027SC-INITIAL SHINE SERVICES, INDIVIDUAL 13 22.00 1100.00 50.00
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 4433 24778.0 1654332.90 66.77
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 26 85.00 4617.20 54.32
SPL-92508-GROUP SPL SESSION PER CHILD 77 400.75 4428.79 11.05
TRAN-TRAN-FAMILY TRANSPORTATION 381 1847.00 22905.62 12.40
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 8349 1747436 942756.76 0.54
VISN-EIIF_NM-EI VISION SERVICES, IND NONMED 21 153.00 7990.00 52.22
Subtotal (Total Children Is Unduplicated) 10926 1856926 6296687.39 3.39
----------------------------------------------------------------------------------------------------------------
Total 1954393.26 10056621.22 5.15
----------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 21108
----------------------------------------------------------------------------------------------------------------
Center 01
Flag Claims Units Chgs Paid
-------------------------------------------------
R 8 5.00 185.00 0.00
U 0 0.00 0.00 0.00
B 3248 2380.75 88838.25 0.00
P 9726 192917.25 380572.89 380572.84
D 9 6.25 321.25 0.00
S 1316 1034.50 38276.50 0.00
H 0 0.00 0.00 0.00
T 1 1.25 46.25 0.00
7685 13014.50 260508.37 0.00
Other 359 424.25 26375.14 0.00
-------------------------------------------------
Total 22352 209783.75 795123.65 380572.84
Center 02
Flag Claims Units Chgs Paid
-------------------------------------------------
R 3 5.75 212.75 0.00
U 0 0.00 0.00 0.00
B 816 3033.25 112842.00 0.00
P 0 192917.25 380572.89 380572.84
D 0 6.25 321.25 0.00
S 0 1034.50 38276.50 0.00
H 0 0.00 0.00 0.00
T 1123 43697.50 62807.91 62749.16
2459 42826.75 357826.08 0.00
Other 1 425.00 26402.89 0.00
-------------------------------------------------
Total 4402 283946.25 979262.27 443322.00
Center 03
Flag Claims Units Chgs Paid
-------------------------------------------------
R 4 8.25 333.00 0.00
U 0 0.00 0.00 0.00
B 660 3502.50 131672.25 37.00
P 5032 241140.50 557950.44 557950.39
D 0 6.25 321.25 0.00
S 0 1034.50 38276.50 0.00
H 0 0.00 0.00 0.00
T 4254 65060.75 182591.28 182532.53
2267 45792.25 417930.49 0.00
Other 195 621.25 29422.06 0.00
-------------------------------------------------
Total 12412 357166.25 1358497.27 740519.92
Center 04
Flag Claims Units Chgs Paid
-------------------------------------------------
R 2 10.25 420.00 0.00
U 0 0.00 0.00 0.00
B 3421 6898.50 265663.25 37.00
P 3677 351988.02 788996.95 789148.47
D 11 139.25 1488.23 1187.32
S 0 1034.50 38276.50 0.00
H 836 2624.82 136387.76 136630.12
T 0 65060.75 182591.28 182532.53
6098 55763.75 770802.43 0.00
Other 0 621.25 29422.06 0.00
-------------------------------------------------
Total 14045 484141.09 2214048.46 1109535.44
Center 05
Flag Claims Units Chgs Paid
-------------------------------------------------
R 58 45.75 1733.50 0.00
U 0 0.00 0.00 0.00
B 2278 8144.50 312501.31 37.00
P 3284 441170.72 936874.34 937025.86
D 0 139.25 1488.23 1187.32
S 0 1034.50 38276.50 0.00
H 0 2624.82 136387.76 136630.12
T 0 65060.75 182591.28 182532.53
6306 60294.37 957779.46 0.00
Other 0 621.25 29422.06 0.00
-------------------------------------------------
Total 11926 579135.91 2597054.44 1257412.83
Center 06
Flag Claims Units Chgs Paid
-------------------------------------------------
R 8 49.75 1881.50 111.00
U 0 0.00 0.00 0.00
B 2096 9602.50 366447.31 37.00
P 11436 571828.22 1253544.55 1253696.07
D 0 139.25 1488.23 1187.32
S 0 1034.50 38276.50 0.00
H 0 2624.82 136387.76 136630.12
T 1 65061.00 182600.53 182532.53
16369 109418.37 1493975.27 157.25
Other 0 621.25 29422.06 0.00
-------------------------------------------------
Total 29910 760379.66 3504023.71 1574351.29
Center 07
Flag Claims Units Chgs Paid
-------------------------------------------------
R 21 76.50 3384.25 111.00
U 0 0.00 0.00 0.00
B 3707 12187.75 470841.62 37.00
P 3256 675447.22 1578276.68 1578428.20
D 0 139.25 1488.23 1187.32
S 207 1151.75 42727.75 0.00
H 0 2624.82 136387.76 136630.12
T 0 65061.00 182600.53 182532.53
9552 123893.62 1804737.63 157.25
Other 0 621.25 29422.06 0.00
-------------------------------------------------
Total 16743 881203.16 4249866.51 1899083.42
Center 09
Flag Claims Units Chgs Paid
-------------------------------------------------
R 35 99.25 4226.00 111.00
U 0 0.00 0.00 0.00
B 653 12734.00 498192.65 466.50
P 16297 842660.97 2352319.36 2435979.20
D 0 139.25 1488.23 1187.32
S 0 1151.75 42727.75 0.00
H 0 2624.82 136387.76 136630.12
T 0 65061.00 182600.53 182532.53
4119 131996.37 2200559.73 1705.61
Other 6 623.25 29496.06 0.00
-------------------------------------------------
Total 21110 1057090.66 5447998.07 2758612.28
Center 10
Flag Claims Units Chgs Paid
-------------------------------------------------
R 66 147.75 6020.50 111.00
U 0 0.00 0.00 0.00
B 4521 15844.25 618620.90 549.75
P 6535 940710.97 2754862.47 2838522.31
D 41 159.00 2218.98 1918.07
S 289 1321.25 49841.00 0.00
H 0 2624.82 136387.76 136630.12
T 0 65061.00 182600.53 182532.53
11006 142666.62 2643286.03 1705.61
Other 0 623.25 29496.06 0.00
-------------------------------------------------
Total 22458 1169158.91 6423334.23 3161969.39
Center 51
Flag Claims Units Chgs Paid
-------------------------------------------------
R 2 148.75 6057.50 111.00
U 0 0.00 0.00 0.00
B 3387 18197.50 708441.62 549.75
P 2217 1042093.72 2923309.34 3006959.93
D 20 173.00 2743.98 1918.07
S 0 1321.25 49841.00 0.00
H 0 2624.82 136387.76 136630.12
T 0 65061.00 182600.53 182532.53
5005 149486.62 2914005.99 1705.61
Other 0 623.25 29496.06 0.00
-------------------------------------------------
Total 10631 1279729.91 6952883.78 3330407.01
Center 52
Flag Claims Units Chgs Paid
-------------------------------------------------
R 3 153.75 6432.50 111.00
U 0 0.00 0.00 0.00
B 2059 19549.00 767094.69 549.75
P 1 1042094.61 2923369.75 3007020.34
D 0 173.00 2743.98 1918.07
S 24 1341.75 50884.50 0.00
H 63 2725.32 142591.50 136630.12
T 23 66266.00 184043.21 184037.21
7460 273761.14 3302925.83 1879.39
Other 0 623.25 29496.06 0.00
-------------------------------------------------
Total 9633 1406687.82 7409582.02 3332145.88
Center 53
Flag Claims Units Chgs Paid
-------------------------------------------------
R 27 177.25 7530.00 111.00
U 0 0.00 0.00 0.00
B 42 19593.25 769239.94 1016.25
P 2020 1044040.50 3013741.82 3097367.41
D 53 256.00 8647.24 1918.07
S 0 1341.75 50884.50 0.00
H 2279 34057.56 211743.32 205747.47
T 1464 98710.11 240156.69 240168.57
4125 309105.15 3473606.44 2629.39
Other 12 647.25 31087.06 0.00
-------------------------------------------------
Total 10022 1507928.82 7806637.01 3548958.16
Center 54
Flag Claims Units Chgs Paid
-------------------------------------------------
R 3 179.00 7594.75 111.00
U 0 0.00 0.00 0.00
B 1241 20651.50 819837.94 1016.25
P 6053 1202840.32 3447464.69 3527998.54
D 77 309.50 10626.74 1918.07
S 1 1342.25 50903.00 0.00
H 0 34057.56 211743.32 205747.47
T 0 98710.11 240156.69 240168.57
6602 348183.17 3819136.79 2629.39
Other 2 648.75 31142.56 0.00
-------------------------------------------------
Total 13979 1706922.16 8638606.48 3979589.29
Center 55
Flag Claims Units Chgs Paid
-------------------------------------------------
R 0 179.00 7594.75 111.00
U 0 0.00 0.00 0.00
B 9 20660.75 820237.19 1016.25
P 3793 1238597.16 3575295.17 3655866.52
D 47 362.00 12683.24 1918.07
S 17 1360.50 51616.75 0.00
H 0 34057.56 211743.32 205747.47
T 2078 127390.68 306157.57 306169.45
4647 351900.86 4000836.07 2629.39
Other 0 648.75 31142.56 0.00
-------------------------------------------------
Total 10591 1775157.26 9017306.62 4173458.15
Center 57
Flag Claims Units Chgs Paid
-------------------------------------------------
R 259 448.00 18148.25 111.00
U 0 0.00 0.00 0.00
B 385 21057.75 837339.69 1016.25
P 1354 1240062.66 3632884.17 3713474.02
D 93 459.75 16487.99 1918.07
S 207 5135.50 68184.13 16567.38
H 0 34057.56 211743.32 205747.47
T 5836 275496.18 689112.13 689635.15
6269 376765.61 4548002.70 164821.98
Other 42 910.25 34718.84 3678.09
-------------------------------------------------
Total 14445 1954393.2610056621.22 4796969.41