CMS/EIP Fiscal Report Statewide
Services beginning 04/01/2009 ending 06/30/2009 Date of Report:08/25/2009 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 7216 4544.75 168155.75 37.00
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 5858 6627.00 0.00 0.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 6842 7411.75 274117.50 36.98
TCM-T1017TL-TARGETED CASE MANAGEMENT 10184 31598.0 1167840.25 36.96
TCON-TCON-TRANSITION CONFERENCE 1208 1307.00 0.00 0.00
Subtotal (Total Children Is Unduplicated) 17016 51488.5 1610113.50 31.27
----------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
ASTE-ASTE-ASSISTIVE TECHNOLOGY EVAL 14 15.00 610.00 40.67
AUDE-92552-PURE TONE AUDIOMETRY -AIR ONLY 36 36.00 382.32 10.62
AUDE-92553-PURE TONE AUDIOMETRY AIR & BONE 5 5.00 81.50 16.30
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 79 80.00 705.50 8.82
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 98 99.91 1061.56 10.63
AUDE-92568-ACOUSTIC REFLEX TESTING (MEMR) 5 5.00 42.20 8.44
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 95 95.10 2036.73 21.42
AUDE-92585-AUD EVOKED RESPONSE (DIAG) 4 4.00 217.52 54.38
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 40 39.36 1113.20 28.28
AUDE-92588-OTOACOUSTIC EMISSIONS (COMP) 13 13.00 413.53 31.81
AUDE-92682-CONDITIONED PLAY AUDIOMETRY 1 1.00 21.34 21.34
AUDE-V5010-ASSESSMENT FOR HEARING AID 5 5.00 247.20 49.44
AUDE-V5090-DISPENSING FEE PER HEARING AID 5 8.00 888.80 111.10
BEHV-H0031HO-COMP BEHAVIORAL HEALTH ASSESSMENT 18 22.00 1790.00 81.36
EVAL-EVAL-DEVELOPMENTAL EVALUATION 75 78.75 3945.75 50.10
EXIT-EXIT-TRANSITION ASSESSMENT 373 571.50 28645.75 50.12
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 61 95.50 7125.00 74.61
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 14 22.00 1650.00 75.00
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 17 23.00 1681.00 73.09
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 49 66.00 4912.50 74.43
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 62 99.50 5522.25 55.50
IPDEI-IPDEI_NM-INITIAL PSYCH & DEV EVAL BY NON-MED PR 95 139.15 7366.25 52.94
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 904 1320.81 98523.80 74.59
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 274 446.03 31890.48 71.50
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 187 252.28 18587.66 73.68
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 1019 1661.18 92074.41 55.43
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 563 843.73 62866.65 74.51
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 10 10.00 1272.00 127.20
MED-99204-OUTPATIENT VISIT, NEW, 45 MINS 5 5.00 286.35 57.27
MED-99205-OUTPATIENT VISIT, NEW, 60 MINS 4 4.00 291.12 72.78
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 1 1.00 105.00 105.00
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 44 42.92 1870.78 43.59
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 128 128.79 6047.10 46.95
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 23 23.07 1048.71 45.46
PSTH-97001-EVAL BY LICENSED PT, INITIAL 75 76.00 3468.19 45.63
SCREEN-T1023-INTERDISCIPLINARY SCREENING 200 201.00 10050.00 50.00
SPCH-92506-SPEECH EVAL BY LICENSED SLP 294 295.08 14126.13 47.87
VISD-VISD-VISION EVALUATION DIAGNOSTIC 1 60.00 30.00 0.50
VISF-VISF-VISION EVALUATION FUNCTIONAL 1 2.00 140.00 70.00
Subtotal (Total Children Is Unduplicated) 3015 6903.91 413525.53 59.90
----------------------------------------------------------------------------------------------------------------
EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 44 144.00 33620.02 233.47
AUD-92630-AUD REHAB PRELING HEARING LOSS 1 2.00 137.72 68.86
AUD-HA_FUP-AUDIOLOGY SERVICES 10 12.00 546.07 45.51
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 778 913.75 44782.00 49.01
COIFP-COIFP-IFSP CONSULT, PRO, BY PHONE 68 42.25 1038.50 24.58
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 960 1612.00 80542.50 49.96
CONIP-CONIP-CONSULT, ITDS, PHONE 232 397.25 9931.25 25.00
CONOF-CONOF-CONSULT, OT, FACE TO FACE 262 329.75 16311.98 49.47
CONOP-CONOP-CONSULT, OT, PHONE 32 39.75 1026.63 25.83
CONPF-CONPF-CONSULT, PT, FACE TO FACE 201 239.50 12067.06 50.38
CONPP-CONPP-CONSULT, PT, PHONE 18 11.50 268.75 23.37
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 964 1599.25 80123.75 50.10
CONSP-CONSP-CONSULT, SLP, PHONE 236 380.00 9481.25 24.95
COUN-H2019HR-INDIVIDUAL/FAMILY THERAPY 11 40.00 1430.00 35.75
EIGF-EIGF_NM-EI GROUP SESSION BY NONMED PROF 20 45.00 1245.00 27.67
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 68 333.50 9290.00 27.86
EIIF-96154-HEALTH AND BEHAVIOR INTERVENTION 44 446.50 22312.50 49.97
EIIF-EIIF_NM-EI INDIVIDUAL SESSION BY NONMED PROF 182 1025.36 43369.50 42.30
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 2434 18267.3 899340.24 49.23
HERN-T1027SC-EI HEARING SERVICES AFTER SHINE 26 58.75 2937.50 50.00
INTR-INTR-INTERPRETER 177 876.75 37044.13 42.25
OCCT-97530-OT SESSION BY LICENSED OT 1069 5681.22 359286.51 63.24
OCCT-97530HM-OT SESSION BY OT ASST 25 80.75 4102.18 50.80
PHY-97110-PT SESSION BY LICENSED PT 871 4236.08 270397.95 63.83
PHY-97110HM-PT SESSION BY PT ASST 13 40.04 2165.21 54.08
RSPT-RSPT-RESPITE 1 97.50 756.00 7.75
CMS/EIP Fiscal Report Statewide
Services beginning 04/01/2009 ending 06/30/2009 Date of Report:08/25/2009 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-FM-FM RECEIVER HEARING AID 1 1.00 1267.00 1267.00
SENS-HA_EIP-ONE UNIT UP TO $500 PER AID 2 3.00 1500.00 500.00
SENS-V5050-MED HEARING AID - ANALOG/DIGITAL 2 4.00 948.48 237.12
SENS-V5264-EARMOLD 15 28.00 524.16 18.72
SHIN-T1027SC-INITIAL SHINE SERVICES, INDIVIDUAL 8 20.00 1000.00 50.00
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 3064 18228.9 1198282.04 65.74
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 15 45.50 2390.04 52.53
SPL-92508-GROUP SPL SESSION PER CHILD 33 138.50 1929.67 13.93
TRAN-TRAN-FAMILY TRANSPORTATION 354 759.00 9518.24 12.54
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 9219 1971285 1055184.28 0.54
VISN-EIIF_NM-EI VISION SERVICES, IND NONMED 25 74.25 3782.50 50.94
VISN-T1027SC-EI VISION SERVICES, INDIVIDUAL 4 39.00 1950.00 50.00
Subtotal (Total Children Is Unduplicated) 11086 2027578 4221830.61 2.08
----------------------------------------------------------------------------------------------------------------
Total 2085970.28 6245469.64 2.99
----------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 19520
----------------------------------------------------------------------------------------------------------------
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 7043 143957.50 279905.75 279905.75
D 2 1.50 34.44 0.00
S 495 3516.25 16492.25 0.00
H 2 3.00 150.00 0.00
T 5727 94173.25 241092.13 241092.13
7201 5180.75 164954.27 0.00
Other 303 3877.75 16572.28 0.00
-------------------------------------------------
Total 20773 250710.00 719201.12 520997.88
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 143957.50 279905.75 279905.75
D 0 1.50 34.44 0.00
S 0 3516.25 16492.25 0.00
H 0 3.00 150.00 0.00
T 1773 154998.50 327485.88 327485.88
1803 30442.25 232858.86 0.00
Other 0 3877.75 16572.28 0.00
-------------------------------------------------
Total 3576 336796.75 873499.46 607391.63
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 4512 200430.75 440476.44 440476.44
D 0 1.50 34.44 0.00
S 0 3516.25 16492.25 0.00
H 0 3.00 150.00 0.00
T 5030 173726.50 459660.05 459660.05
2688 39143.75 308673.99 0.00
Other 4 3881.75 16685.56 0.00
-------------------------------------------------
Total 12234 420703.50 1242172.73 900136.49
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 3211 353844.37 685266.88 685266.94
D 108 664.25 4693.75 1995.31
S 0 3516.25 16492.25 0.00
H 18 161.50 2731.16 2547.25
T 0 173726.50 459660.05 459660.05
5440 43212.25 444893.49 0.00
Other 0 3881.75 16685.56 0.00
-------------------------------------------------
Total 8777 579006.87 1630423.14 1149469.55
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 3570 449717.46 840558.00 840558.06
D 0 664.25 4693.75 1995.31
S 0 3516.25 16492.25 0.00
H 0 161.50 2731.16 2547.25
T 0 173726.50 459660.05 459660.05
3463 45316.50 510319.87 0.00
Other 0 3881.75 16685.56 0.00
-------------------------------------------------
Total 7033 676984.21 1851140.64 1304760.67
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 13540 614820.46 1206792.18 1206792.24
D 0 664.25 4693.75 1995.31
S 0 3516.25 16492.25 0.00
H 0 161.50 2731.16 2547.25
T 0 173726.50 459660.05 459660.05
7148 50337.00 664060.52 888.00
Other 0 3881.75 16685.56 0.00
-------------------------------------------------
Total 20688 847107.71 2371115.47 1671882.85
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 3366 734237.96 1552071.74 1552071.80
D 0 664.25 4693.75 1995.31
S 20 3529.25 16973.25 0.00
H 0 161.50 2731.16 2547.25
T 0 173726.50 459660.05 459660.05
8913 60951.25 858861.33 888.00
Other 0 3881.75 16685.56 0.00
-------------------------------------------------
Total 12299 977152.46 2911676.84 2017162.41
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 9463 856616.21 2008560.71 2008692.97
D 0 664.25 4693.75 1995.31
S 0 3529.25 16973.25 0.00
H 0 161.50 2731.16 2547.25
T 5135 244400.50 720574.59 720574.59
391 65155.50 882325.10 2867.59
Other 0 3881.75 16685.56 0.00
-------------------------------------------------
Total 14989 1174408.96 3652544.12 2736677.71
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 4364 967246.96 2361534.34 2361666.60
D 73 714.00 6534.50 3836.06
S 0 3529.25 16973.25 0.00
H 0 161.50 2731.16 2547.25
T 0 244400.50 720574.59 720574.59
9084 71837.50 1100645.60 2867.59
Other 0 3881.75 16685.56 0.00
-------------------------------------------------
Total 13522 1291771.71 4225688.25 3091492.09
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 2256 1071917.71 2531771.94 2531904.20
D 13 724.75 6977.25 3836.06
S 0 3529.25 16973.25 0.00
H 0 161.50 2731.16 2547.25
T 0 244400.50 720574.59 720574.59
3826 75370.25 1190661.94 2867.59
Other 0 3881.75 16685.56 0.00
-------------------------------------------------
Total 6095 1399985.96 4486384.94 3261729.69
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 548 1099711.48 2566136.88 2566269.14
D 0 724.75 6977.25 3836.06
S 1 3530.75 17075.07 0.00
H 1 163.00 2814.41 2547.25
T 0 244400.50 720574.59 720574.59
5925 169970.70 1355013.50 2867.59
Other 0 3881.75 16685.56 0.00
-------------------------------------------------
Total 6475 1522383.18 4685286.51 3296094.63
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 1301 1136592.04 2614204.90 2614337.16
D 9 732.75 7299.25 3836.06
S 0 3530.75 17075.07 0.00
H 1430 36993.75 60129.95 59862.79
T 2278 270549.00 778278.05 778278.05
1628 184511.28 1395721.14 2867.59
Other 0 3881.75 16685.56 0.00
-------------------------------------------------
Total 6646 1636791.57 4889403.17 3459181.65
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 3450 1300627.58 2980373.54 2980505.80
D 260 908.50 14216.00 3836.06
S 0 3530.75 17075.07 0.00
H 0 36993.75 60129.95 59862.79
T 0 270549.00 778278.05 778278.05
5389 218597.61 1564924.34 2867.59
Other 0 3881.75 16685.56 0.00
-------------------------------------------------
Total 9099 1835089.19 5431691.76 3825350.29
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 3036 1346802.69 3074779.93 3074912.19
D 55 963.50 16764.00 3836.06
S 0 3530.75 17075.07 0.00
H 0 36993.75 60129.95 59862.79
T 0 270549.00 778278.05 778278.05
4263 255348.59 1682840.71 2867.59
Other 0 3881.75 16685.56 0.00
-------------------------------------------------
Total 7354 1918070.28 5646562.52 3919756.68
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 0 1346802.69 3074779.93 3074912.19
D 62 1026.25 19622.00 3836.06
S 29 4239.25 18719.03 1643.96
H 0 36993.75 60129.95 59862.79
T 6751 432963.00 1226639.73 1227001.05
4210 260062.34 1828834.19 4097.57
Other 1 3882.75 16735.56 50.00
-------------------------------------------------
Total 11053 2085970.28 6245469.64 4371403.62