CMS/EIP Fiscal Report Statewide
Services beginning 01/01/2009 ending 03/31/2009 Date of Report:05/18/2009 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 6681 4174.25 154354.75 36.98
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 5693 6245.00 0.00 0.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 6282 6826.00 252386.25 36.97
TCM-T1017TL-TARGETED CASE MANAGEMENT 9789 30414.0 1123994.25 36.96
TCON-TCON-TRANSITION CONFERENCE 1144 1154.00 0.00 0.00
Subtotal (Total Children Is Unduplicated) 16322 48813.3 1530735.25 31.36
----------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
ASTE-ASTE-ASSISTIVE TECHNOLOGY EVAL 12 12.00 535.00 44.58
AUDE-92552-PURE TONE AUDIOMETRY -AIR ONLY 22 22.00 233.64 10.62
AUDE-92553-PURE TONE AUDIOMETRY AIR & BONE 7 7.00 112.34 16.05
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 58 60.00 528.90 8.82
AUDE-92557-COMP AUDIO THRESHOLD EVAL/SPCH RECOG 2 3.00 72.10 24.03
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 73 77.00 822.78 10.69
AUDE-92568-ACOUSTIC REFLEX TESTING (MEMR) 10 10.00 84.40 8.44
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 69 70.79 1537.60 21.72
AUDE-92585-AUD EVOKED RESPONSE (DIAG) 1 1.00 54.38 54.38
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 23 25.00 707.00 28.28
AUDE-92588-OTOACOUSTIC EMISSIONS (COMP) 7 7.00 222.67 31.81
AUDE-V5090-DISPENSING FEE PER HEARING AID 5 9.00 998.40 110.93
BEHV-90801-PSYCHIATRIC DIAG INTERVIEW 1 1.00 50.00 50.00
BEHV-H0031HO-COMP BEHAVIORAL HEALTH ASSESSMENT 9 9.00 675.00 75.00
EVAL-EVAL-DEVELOPMENTAL EVALUATION 90 108.00 5490.00 50.83
EXIT-EXIT-TRANSITION ASSESSMENT 258 384.25 19537.50 50.85
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 93 142.50 10687.50 75.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 26 37.34 2800.00 74.99
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 31 41.50 3086.00 74.36
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 75 95.84 7187.50 74.99
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 86 127.50 7076.25 55.50
IPDEI-IPDEI_NM-INITIAL PSYCH & DEV EVAL BY NON-MED PR 68 89.00 4719.75 53.03
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 931 1319.29 98438.09 74.61
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 271 425.68 31699.45 74.47
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 259 324.53 24123.37 74.33
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 1000 1557.93 86416.53 55.47
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 674 1008.18 75275.89 74.67
MED-99202-OUTPATIENT VISIT, NEW, 20 MINS 2 2.00 54.44 27.22
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 19 20.00 2688.50 134.43
MED-99204-OUTPATIENT VISIT, NEW, 45 MINS 2 2.00 114.54 57.27
MED-99205-OUTPATIENT VISIT, NEW, 60 MINS 3 3.00 218.34 72.78
NUTR-97802-NUTRITIONAL EVAL, INITIAL 1 1.00 50.00 50.00
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 42 42.00 1916.37 45.63
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 97 99.00 4772.00 48.20
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 17 15.33 702.49 45.82
PSTH-97001-EVAL BY LICENSED PT, INITIAL 52 53.61 2409.27 44.94
SCREEN-T1023-INTERDISCIPLINARY SCREENING 192 193.00 9650.00 50.00
SPCH-92506-SPEECH EVAL BY LICENSED SLP 272 273.07 13130.19 48.08
VISD-VISD-VISION EVALUATION DIAGNOSTIC 1 40.00 20.00 0.50
VISF-VISF-VISION EVALUATION FUNCTIONAL 3 6.00 420.00 70.00
Subtotal (Total Children Is Unduplicated) 2970 6733.84 419773.43 62.34
----------------------------------------------------------------------------------------------------------------
EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 41 103.00 18206.64 176.76
AUD-92630-AUD REHAB PRELING HEARING LOSS 2 6.00 413.16 68.86
AUD-HA_FUP-AUDIOLOGY SERVICES 8 10.00 474.69 47.47
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 712 882.25 40434.80 45.83
COIFP-COIFP-IFSP CONSULT, PRO, BY PHONE 49 30.00 720.00 24.00
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 904 1484.75 69355.00 46.71
CONIP-CONIP-CONSULT, ITDS, PHONE 314 521.00 13002.50 24.96
CONOF-CONOF-CONSULT, OT, FACE TO FACE 247 275.50 13695.16 49.71
CONOP-CONOP-CONSULT, OT, PHONE 42 44.00 1095.00 24.89
CONPF-CONPF-CONSULT, PT, FACE TO FACE 182 224.50 11099.13 49.44
CONPP-CONPP-CONSULT, PT, PHONE 31 19.50 470.75 24.14
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 840 1334.50 65101.33 48.78
CONSP-CONSP-CONSULT, SLP, PHONE 287 502.50 12505.00 24.89
COUN-H2019HR-INDIVIDUAL/FAMILY THERAPY 10 48.00 1540.00 32.08
ECE-ECE-EARLY CHILDHOOD EDUCATION 1 20.00 250.00 12.50
EIGF-EIGF_NM-EI GROUP SESSION BY NONMED PROF 13 83.50 1257.50 15.06
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 60 795.75 9818.75 12.34
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 200 1098.74 46048.49 41.91
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 2358 17338.7 842739.10 48.60
HERN-T1027SC-EI HEARING SERVICES AFTER SHINE 4 11.50 575.00 50.00
INTR-INTR-INTERPRETER 128 802.00 29620.25 36.93
OCCT-97530-OT SESSION BY LICENSED OT 1013 5194.31 333642.59 64.23
OCCT-97530HM-OT SESSION BY OT ASST 39 107.00 5540.48 51.78
PHY-97110-PT SESSION BY LICENSED PT 857 3950.49 256256.46 64.87
PHY-97110HM-PT SESSION BY PT ASST 8 17.25 937.02 54.32
CMS/EIP Fiscal Report Statewide
Services beginning 01/01/2009 ending 03/31/2009 Date of Report:05/18/2009 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
RSPT-RSPT-RESPITE 1 53.00 424.00 8.00
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 10 19.00 352.80 18.57
SHIN-T1027SC-INITIAL SHINE SERVICES, INDIVIDUAL 8 12.50 625.00 50.00
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 2775 15652.2 1030991.66 65.87
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 19 68.50 3720.92 54.32
SPL-92508-GROUP SPL SESSION PER CHILD 23 151.75 977.51 6.44
TRAN-TRAN-FAMILY TRANSPORTATION 358 579.00 4893.62 8.45
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 8321 1744282 940852.38 0.54
VISN-EIIF_NM-EI VISION SERVICES, IND NONMED 4 28.25 1692.50 59.91
Subtotal (Total Children Is Unduplicated) 10039 1796197 3783627.93 2.11
----------------------------------------------------------------------------------------------------------------
Total 1851744.31 5734136.61 3.10
----------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 18562
----------------------------------------------------------------------------------------------------------------
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 9376 192674.00 371572.64 371572.64
D 4 4.00 225.00 0.00
S 258 206.25 7631.25 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
6702 11337.25 161200.38 0.00
Other 29 34.50 2340.76 0.00
-------------------------------------------------
Total 16369 204256.00 542970.03 371572.64
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 192674.00 371572.64 371572.64
D 0 4.00 225.00 0.00
S 0 206.25 7631.25 0.00
H 0 0.00 0.00 0.00
T 1123 43696.25 62761.66 62749.16
2281 40910.25 243211.59 0.00
Other 0 34.50 2340.76 0.00
-------------------------------------------------
Total 3404 277525.25 687742.90 434321.80
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 3693 239866.25 508593.19 508593.19
D 0 4.00 225.00 0.00
S 0 206.25 7631.25 0.00
H 0 0.00 0.00 0.00
T 4254 65059.50 182545.03 182532.53
2065 43697.75 296435.00 0.00
Other 2 36.50 2371.38 0.00
-------------------------------------------------
Total 10014 348870.25 997800.85 691125.72
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 2475 349539.52 692425.43 692426.70
D 11 137.00 1391.98 1187.32
S 0 206.25 7631.25 0.00
H 11 32.00 1671.52 1671.52
T 0 65059.50 182545.03 182532.53
5084 47615.75 427811.00 0.00
Other 0 36.50 2371.38 0.00
-------------------------------------------------
Total 7581 462626.52 1315847.59 877818.07
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 3259 438564.72 839183.32 839184.59
D 0 137.00 1391.98 1187.32
S 0 206.25 7631.25 0.00
H 0 32.00 1671.52 1671.52
T 0 65059.50 182545.03 182532.53
3330 50162.37 490404.36 0.00
Other 0 36.50 2371.38 0.00
-------------------------------------------------
Total 6589 554198.34 1525198.84 1024575.96
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 10550 568638.22 1134060.25 1134061.52
D 0 137.00 1391.98 1187.32
S 0 206.25 7631.25 0.00
H 0 32.00 1671.52 1671.52
T 0 65059.50 182545.03 182532.53
10330 94344.12 727319.27 157.25
Other 0 36.50 2371.38 0.00
-------------------------------------------------
Total 20880 728453.59 2056990.68 1319610.14
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 2969 671834.97 1439966.77 1439968.04
D 0 137.00 1391.98 1187.32
S 5 211.00 7920.00 0.00
H 0 32.00 1671.52 1671.52
T 0 65059.50 182545.03 182532.53
8677 106546.62 919282.61 157.25
Other 0 36.50 2371.38 0.00
-------------------------------------------------
Total 11651 843857.59 2555149.29 1625516.66
Center 09
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 13537 836632.22 2102719.33 2103146.10
D 0 137.00 1391.98 1187.32
S 0 211.00 7920.00 0.00
H 0 32.00 1671.52 1671.52
T 0 65059.50 182545.03 182532.53
979 109341.62 985921.05 1705.61
Other 0 36.50 2371.38 0.00
-------------------------------------------------
Total 14516 1011449.84 3284540.29 2290243.08
Center 10
Flag Claims Units Chgs Paid
-------------------------------------------------
R 0 0.00 0.00 0.00
U 0 0.00 0.00 0.00
B 1 0.25 9.25 0.00
P 3918 932671.72 2408841.19 2409267.96
D 37 153.75 2011.73 1807.07
S 0 211.00 7920.00 0.00
H 0 32.00 1671.52 1671.52
T 0 65059.50 182545.03 182532.53
9396 116750.37 1223075.86 1705.61
Other 0 36.50 2371.38 0.00
-------------------------------------------------
Total 13352 1114915.09 3828445.96 2596984.69
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 0.25 9.25 0.00
P 2174 1033939.72 2570014.32 2570441.09
D 20 167.75 2536.73 1807.07
S 0 211.00 7920.00 0.00
H 0 32.00 1671.52 1671.52
T 0 65059.50 182545.03 182532.53
3748 120620.37 1313124.74 1705.61
Other 0 36.50 2371.38 0.00
-------------------------------------------------
Total 5942 1220067.09 4080192.97 2758157.82
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 0.25 9.25 0.00
P 0 1033939.72 2570014.32 2570441.09
D 0 167.75 2536.73 1807.07
S 0 211.00 7920.00 0.00
H 2 34.50 1804.77 1671.52
T 23 66264.50 183987.71 184037.21
6010 240356.60 1515049.17 1705.61
Other 0 36.50 2371.38 0.00
-------------------------------------------------
Total 6035 1341010.82 4283693.33 2759662.50
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 0.25 9.25 0.00
P 0 1033939.72 2570014.32 2570441.09
D 1 169.75 2647.73 1807.07
S 0 211.00 7920.00 0.00
H 2279 31366.74 70956.59 70788.87
T 1464 98708.61 240101.19 240168.57
2089 273759.45 1584351.96 2405.61
Other 0 36.50 2371.38 0.00
-------------------------------------------------
Total 5833 1438192.02 4478372.42 2885611.21
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 0.25 9.25 0.00
P 3141 1190799.04 2927587.63 2928088.40
D 77 223.25 4627.23 1807.07
S 0 211.00 7920.00 0.00
H 0 31366.74 70956.59 70788.87
T 0 98708.61 240101.19 240168.57
5174 309557.43 1738740.20 2405.61
Other 0 36.50 2371.38 0.00
-------------------------------------------------
Total 8392 1630902.82 4992313.47 3243258.52
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 0.25 9.25 0.00
P 2716 1225517.13 3014928.22 3015428.99
D 47 275.75 6683.73 1807.07
S 0 211.00 7920.00 0.00
H 0 31366.74 70956.59 70788.87
T 2059 127373.68 305273.43 305340.81
1870 311137.76 1782688.65 2405.61
Other 0 36.50 2371.38 0.00
-------------------------------------------------
Total 6692 1695918.81 5190831.25 3395771.35
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 0.25 9.25 0.00
P 1 1225518.38 3014974.47 3015493.74
D 93 373.50 10488.48 1807.07
S 203 3862.50 24225.56 16305.56
H 0 31366.74 70956.59 70788.87
T 5816 275174.93 684498.72 685128.15
4221 315409.01 1926461.84 3138.05
Other 2 39.00 2521.70 150.31
-------------------------------------------------
Total 10336 1851744.31 5734136.61 3792811.75