CMS/EIP Fiscal Report Statewide
Services beginning 04/01/2009 ending 06/30/2009 Date of Report:08/25/2009 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 7220 4546.00 168202.00 37.00
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 5859 6629.00 0.00 0.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 6846 7421.75 274487.50 36.98
TCM-T1017TL-TARGETED CASE MANAGEMENT 20461 67404.3 2491630.00 36.97
TCON-TCON-TRANSITION CONFERENCE 1209 1308.00 0.00 0.00
Subtotal (Total Children Is Unduplicated) 20875 87309.0 2934319.50 33.61
----------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
ASTE-ASTE-ASSISTIVE TECHNOLOGY EVAL 15 16.00 658.50 41.16
AUDE-92552-PURE TONE AUDIOMETRY -AIR ONLY 48 48.00 509.76 10.62
AUDE-92553-PURE TONE AUDIOMETRY AIR & BONE 11 11.00 179.30 16.30
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 316 320.00 2824.70 8.83
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 304 313.00 3361.70 10.74
AUDE-92568-ACOUSTIC REFLEX TESTING (MEMR) 21 22.00 185.68 8.44
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 342 348.00 7536.01 21.66
AUDE-92585-AUD EVOKED RESPONSE (DIAG) 16 16.00 870.08 54.38
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 63 62.36 1745.74 27.99
AUDE-92588-OTOACOUSTIC EMISSIONS (COMP) 51 53.00 1685.93 31.81
AUDE-92682-CONDITIONED PLAY AUDIOMETRY 2 2.00 42.68 21.34
AUDE-V5010-ASSESSMENT FOR HEARING AID 5 5.00 247.20 49.44
AUDE-V5090-DISPENSING FEE PER HEARING AID 6 10.00 1128.00 112.80
BEHV-H0031HO-COMP BEHAVIORAL HEALTH ASSESSMENT 20 24.00 2040.00 85.00
EVAL-EVAL-DEVELOPMENTAL EVALUATION 84 95.75 4795.75 50.09
EXIT-EXIT-TRANSITION ASSESSMENT 379 588.00 29545.75 50.25
IPDEF-IPDEF_NM-F/U PSYCH & DEV EVAL BY NON-MED PROF 3 5.50 299.75 54.50
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 213 319.00 23736.00 74.41
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 56 87.50 6562.50 75.00
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 65 82.00 6053.00 73.82
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 117 180.00 13715.63 76.20
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 167 247.00 13697.50 55.46
IPDEI-IPDEI_NM-INITIAL PSYCH & DEV EVAL BY NON-MED PR 117 169.00 8918.75 52.77
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 2526 3705.01 275625.67 74.39
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 956 1526.00 112980.22 74.04
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 749 979.00 72912.81 74.48
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 2418 3939.50 218611.30 55.49
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 1491 2299.50 174248.92 75.78
MED-99202-OUTPATIENT VISIT, NEW, 20 MINS 5 5.00 136.10 27.22
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 127 127.00 22772.50 179.31
MED-99204-OUTPATIENT VISIT, NEW, 45 MINS 31 32.00 2703.56 84.49
MED-99205-OUTPATIENT VISIT, NEW, 60 MINS 14 14.00 1018.92 72.78
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 27 27.00 2835.00 105.00
MED-99215-OUTPATIENT VISIT, EST, 40 MINS 9 10.00 501.50 50.15
NUTR-97802-NUTRITIONAL EVAL, INITIAL 3 1.50 75.00 50.00
NUTR-97803-NUTRITIONAL EVAL, FOLLOW-UP 1 0.25 12.50 50.00
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 81 89.00 4147.41 46.60
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 255 258.80 12353.20 47.73
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 65 68.00 3228.00 47.47
PSTH-97001-EVAL BY LICENSED PT, INITIAL 182 185.00 8907.42 48.15
SCREEN-T1023-INTERDISCIPLINARY SCREENING 324 326.00 16300.00 50.00
SPCH-92506-SPEECH EVAL BY LICENSED SLP 538 550.50 26512.07 48.16
VISD-VISD-VISION EVALUATION DIAGNOSTIC 2 61.00 130.00 2.13
VISF-VISF-VISION EVALUATION FUNCTIONAL 4 5.25 302.50 57.62
Subtotal (Total Children Is Unduplicated) 6276 17233.4 1086654.51 63.06
----------------------------------------------------------------------------------------------------------------
EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 51 170.00 44404.98 261.21
AUD-92630-AUD REHAB PRELING HEARING LOSS 1 2.00 137.72 68.86
AUD-HA_FUP-AUDIOLOGY SERVICES 12 14.00 646.07 46.15
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 786 926.75 45432.00 49.02
COIFP-COIFP-IFSP CONSULT, PRO, BY PHONE 69 43.25 1063.50 24.59
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 962 1617.00 80792.50 49.96
CONIP-CONIP-CONSULT, ITDS, PHONE 234 399.75 9993.75 25.00
CONOF-CONOF-CONSULT, OT, FACE TO FACE 272 346.00 17124.48 49.49
CONOP-CONOP-CONSULT, OT, PHONE 32 39.75 1026.63 25.83
CONPF-CONPF-CONSULT, PT, FACE TO FACE 205 250.00 12592.06 50.37
CONPP-CONPP-CONSULT, PT, PHONE 18 11.50 268.75 23.37
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 982 1623.75 81348.75 50.10
CONSP-CONSP-CONSULT, SLP, PHONE 236 381.50 9518.75 24.95
COUN-H2019HR-INDIVIDUAL/FAMILY THERAPY 12 41.50 1535.00 36.99
ECE-ECE-EARLY CHILDHOOD EDUCATION 68 8235.00 74115.00 9.00
EIGF-EIGF_NM-EI GROUP SESSION BY NONMED PROF 106 2629.00 65845.00 25.05
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 144 2011.50 51240.00 25.47
EIIF-96154-HEALTH AND BEHAVIOR INTERVENTION 48 466.75 23325.00 49.97
EIIF-EIIF_NM-EI INDIVIDUAL SESSION BY NONMED PROF 328 1891.86 81834.50 43.26
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 4982 37160.4 1843317.38 49.60
HERN-EIIF_NM-EI HEARING SERVICES AFTER SHINE NONMED 10 24.00 1200.00 50.00
HERN-T1027SC-EI HEARING SERVICES AFTER SHINE 30 78.50 3925.00 50.00
INTR-INTR-INTERPRETER 177 876.75 37044.13 42.25
OCCT-97530-OT SESSION BY LICENSED OT 2176 12375.4 817428.69 66.05
CMS/EIP Fiscal Report Statewide
Services beginning 04/01/2009 ending 06/30/2009 Date of Report:08/25/2009 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 118 552.75 29788.68 53.89
PHY-97110-PT SESSION BY LICENSED PT 2105 10954.1 728939.30 66.54
PHY-97110HM-PT SESSION BY PT ASST 87 402.75 22135.37 54.96
RSPT-RSPT-RESPITE 1 97.50 756.00 7.75
SENS-FM-FM RECEIVER HEARING AID 1 1.00 1267.00 1267.00
SENS-HA_EIP-ONE UNIT UP TO $500 PER AID 3 5.00 2500.00 500.00
SENS-V5050-MED HEARING AID - ANALOG/DIGITAL 2 4.00 948.48 237.12
SENS-V5264-EARMOLD 21 40.00 748.80 18.72
SHIN-T1027SC-INITIAL SHINE SERVICES, INDIVIDUAL 16 33.50 1675.00 50.00
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 5060 29236.4 1953609.24 66.82
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 31 77.75 4141.86 53.27
SPL-92508-GROUP SPL SESSION PER CHILD 85 250.00 3703.92 14.82
TRAN-TRAN-FAMILY TRANSPORTATION 354 759.00 9518.24 12.54
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 9245 1981328 1058293.53 0.53
VISN-EIIF_NM-EI VISION SERVICES, IND NONMED 38 141.50 7145.00 50.49
VISN-T1027SC-EI VISION SERVICES, INDIVIDUAL 5 125.00 6250.00 50.00
Subtotal (Total Children Is Unduplicated) 12219 2095624 7136580.06 3.41
----------------------------------------------------------------------------------------------------------------
Total 2200166.61 11157554.07 5.07
----------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 22212
----------------------------------------------------------------------------------------------------------------
Center 01
Flag Claims Units Chgs Paid
-------------------------------------------------
R 109 123.25 7777.00 0.00
U 0 0.00 0.00 0.00
B 2448 1728.50 66954.25 0.00
P 8611 145100.50 323666.00 323665.50
D 216 260.50 17050.44 0.00
S 2290 4935.25 68995.25 0.00
H 23 32.50 1954.99 0.00
T 5727 94173.25 241092.13 241092.13
8325 7087.50 276887.17 11.88
Other 742 4664.50 54528.30 0.00
-------------------------------------------------
Total 28491 258105.75 1058905.53 564769.51
Center 02
Flag Claims Units Chgs Paid
-------------------------------------------------
R 12 132.50 8119.25 0.00
U 0 0.00 0.00 0.00
B 1045 2594.00 98811.25 0.00
P 0 145100.50 323666.00 323665.50
D 0 260.50 17050.44 0.00
S 1 4936.50 69041.50 0.00
H 0 32.50 1954.99 0.00
T 1773 154998.50 327485.88 327485.88
1973 32588.50 359223.01 11.88
Other 0 4664.50 54528.30 0.00
-------------------------------------------------
Total 4804 345308.00 1259880.62 651163.26
Center 03
Flag Claims Units Chgs Paid
-------------------------------------------------
R 3 133.25 8147.00 0.00
U 0 0.00 0.00 0.00
B 77 2641.00 100604.00 0.00
P 6708 203224.50 551025.19 558159.19
D 0 260.50 17050.44 0.00
S 0 4936.50 69041.50 0.00
H 0 32.50 1954.99 0.00
T 5030 173726.50 459660.05 459660.05
3042 41597.75 444944.84 11.88
Other 199 4864.50 57819.13 27.75
-------------------------------------------------
Total 15059 431417.00 1710247.14 1017858.87
Center 04
Flag Claims Units Chgs Paid
-------------------------------------------------
R 30 160.25 9146.00 0.00
U 0 0.00 0.00 0.00
B 2043 4699.75 186180.25 0.00
P 5791 359285.87 901052.01 904971.79
D 112 934.25 22283.05 2565.01
S 0 4936.50 69041.50 0.00
H 1411 4720.60 241581.82 239745.21
T 0 173726.50 459660.05 459660.05
6349 50747.75 753984.26 461.88
Other 0 4864.50 57819.13 27.75
-------------------------------------------------
Total 15736 604075.97 2700748.07 1607431.69
Center 05
Flag Claims Units Chgs Paid
-------------------------------------------------
R 1 161.25 9218.78 0.00
U 0 0.00 0.00 0.00
B 2378 5991.25 234363.95 0.00
P 3790 456389.96 1072015.38 1075888.91
D 0 934.25 22283.05 2565.01
S 0 4936.50 69041.50 0.00
H 0 4720.60 241581.82 239745.21
T 1 173728.75 459743.30 459660.05
6088 54776.36 933101.85 461.88
Other 0 4864.50 57819.13 27.75
-------------------------------------------------
Total 12258 706503.42 3099168.76 1778348.81
Center 06
Flag Claims Units Chgs Paid
-------------------------------------------------
R 0 161.25 9218.78 0.00
U 0 0.00 0.00 0.00
B 1633 7187.25 278615.95 619.75
P 15080 622683.21 1490724.81 1494560.84
D 0 934.25 22283.05 2565.01
S 0 4936.50 69041.50 0.00
H 0 4720.60 241581.82 239745.21
T 0 173728.75 459743.30 459660.05
13517 64833.61 1390724.27 1349.88
Other 0 4864.50 57819.13 27.75
-------------------------------------------------
Total 30230 884049.92 4019752.61 2198528.49
Center 07
Flag Claims Units Chgs Paid
-------------------------------------------------
R 21 171.75 9740.28 0.00
U 0 0.00 0.00 0.00
B 1178 7916.75 306390.45 619.75
P 6894 744651.21 1945539.89 1949375.92
D 0 934.25 22283.05 2565.01
S 84 4984.50 70817.50 0.00
H 0 4720.60 241581.82 239745.21
T 0 173728.75 459743.30 459660.05
10131 78698.86 1768674.85 1349.88
Other 0 4864.50 57819.13 27.75
-------------------------------------------------
Total 18308 1020671.17 4882590.27 2653343.57
Center 09
Flag Claims Units Chgs Paid
-------------------------------------------------
R 6 179.50 10027.03 0.00
U 0 0.00 0.00 0.00
B 899 8750.00 345988.27 824.01
P 12739 870017.96 2542003.95 2548113.21
D 0 934.25 22283.05 2565.01
S 0 4984.50 70817.50 0.00
H 0 4720.60 241581.82 239745.21
T 5135 244402.75 720657.84 720574.59
3659 88926.86 2177891.12 3866.98
Other 0 4864.50 57819.13 27.75
-------------------------------------------------
Total 22438 1227780.92 6189069.71 3515716.76
Center 10
Flag Claims Units Chgs Paid
-------------------------------------------------
R 19 188.75 10369.28 0.00
U 0 0.00 0.00 0.00
B 5948 12740.50 504084.27 824.01
P 5866 982022.46 2968395.02 2974470.34
D 73 984.00 24123.80 4405.76
S 608 5422.75 87032.75 0.00
H 0 4720.60 241581.82 239745.21
T 0 244402.75 720657.84 720574.59
11742 101005.36 2717815.36 3866.98
Other 0 4864.50 57819.13 27.75
-------------------------------------------------
Total 24256 1356351.67 7331879.27 3943914.64
Center 51
Flag Claims Units Chgs Paid
-------------------------------------------------
R 4 190.50 10434.03 0.00
U 0 0.00 0.00 0.00
B 3208 15030.50 590542.37 824.01
P 2313 1087977.71 3145572.95 3151648.27
D 13 994.75 24566.55 4405.76
S 0 5422.75 87032.75 0.00
H 0 4720.60 241581.82 239745.21
T 0 244402.75 720657.84 720574.59
5321 108136.61 3029948.65 3866.98
Other 1 4866.00 57931.63 27.75
-------------------------------------------------
Total 10860 1471742.17 7908268.59 4121092.57
Center 52
Flag Claims Units Chgs Paid
-------------------------------------------------
R 0 190.50 10434.03 0.00
U 0 0.00 0.00 0.00
B 2502 16805.75 669319.16 824.01
P 548 1115771.48 3179937.89 3186013.21
D 0 994.75 24566.55 4405.76
S 20 5444.75 88200.82 0.00
H 91 4887.85 252506.39 239745.21
T 0 244402.75 720657.84 720574.59
7450 211328.85 3378900.19 3866.98
Other 0 4866.00 57931.63 27.75
-------------------------------------------------
Total 10611 1604692.68 8382454.50 4155457.51
Center 53
Flag Claims Units Chgs Paid
-------------------------------------------------
R 3 191.25 10461.78 0.00
U 0 0.00 0.00 0.00
B 10 16815.00 669736.91 824.01
P 3517 1154843.50 3333663.61 3339738.93
D 55 1049.50 26699.05 4405.76
S 0 5444.75 88200.82 0.00
H 1430 41718.60 309821.93 297060.75
T 2278 270551.25 778361.30 778278.05
3994 228053.63 3535894.64 3866.98
Other 0 4866.00 57931.63 27.75
-------------------------------------------------
Total 11287 1723533.48 8810771.67 4424202.23
Center 54
Flag Claims Units Chgs Paid
-------------------------------------------------
R 6 194.50 10582.03 0.00
U 0 0.00 0.00 0.00
B 100 16911.75 675096.92 824.01
P 7439 1321661.04 3814249.76 3818256.96
D 260 1225.25 33615.80 4405.76
S 0 5444.75 88200.82 0.00
H 0 41718.60 309821.93 297060.75
T 1 270551.50 778370.55 778278.05
6871 265657.09 3905486.29 3866.98
Other 1 4867.50 58014.88 27.75
-------------------------------------------------
Total 14678 1928231.98 9673438.98 4902720.26
Center 55
Flag Claims Units Chgs Paid
-------------------------------------------------
R 5 199.25 10757.78 0.00
U 0 0.00 0.00 0.00
B 0 16911.75 675096.92 824.01
P 4129 1368925.40 3952210.21 3956217.41
D 56 1281.25 36200.80 4405.76
S 2 5447.00 88284.07 0.00
H 0 41718.60 309821.93 297060.75
T 0 270551.50 778370.55 778278.05
8006 305149.86 4200910.65 3866.98
Other 0 4867.50 58014.88 27.75
-------------------------------------------------
Total 12198 2015052.1110109667.79 5040680.71
Center 57
Flag Claims Units Chgs Paid
-------------------------------------------------
R 118 348.75 16458.78 0.00
U 0 0.00 0.00 0.00
B 466 17449.75 697458.17 824.01
P 1850 1370897.65 4030819.21 4034826.41
D 62 1344.00 39058.80 4405.76
S 29 6155.50 89928.03 1643.96
H 0 41718.60 309821.93 297060.75
T 6765 433004.00 1228773.45 1229042.27
6172 323923.36 4683141.16 214827.93
Other 54 5325.00 62094.54 4244.11
-------------------------------------------------
Total 15516 2200166.6111157554.07 5786875.20