CMS/EIP Fiscal Report Statewide
Services beginning 07/01/2009 ending 09/30/2009 Date of Report:11/17/2009 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 6882 4510.00 166805.25 36.99
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 5910 6789.00 0.00 0.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 6308 6987.25 258361.75 36.98
TCM-T1017TL-TARGETED CASE MANAGEMENT 20062 67317.3 2488174.25 36.96
TCON-TCON-TRANSITION CONFERENCE 826 829.00 0.00 0.00
Subtotal (Total Children Is Unduplicated) 20488 86432.5 2913341.25 33.71
----------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
ASTE-ASTE-ASSISTIVE TECHNOLOGY EVAL 19 20.00 898.00 44.90
AUD-92626-EVAL OF AUD REHAB STATUS 3 3.00 108.21 36.07
AUDE-92552-PURE TONE AUDIOMETRY -AIR ONLY 37 39.00 409.22 10.49
AUDE-92553-PURE TONE AUDIOMETRY AIR & BONE 6 6.00 102.37 17.06
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 247 252.00 2217.41 8.80
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 249 258.00 2767.45 10.73
AUDE-92568-ACOUSTIC REFLEX TESTING (MEMR) 8 8.00 60.64 7.58
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 256 265.00 5690.40 21.47
AUDE-92585-AUD EVOKED RESPONSE (DIAG) 8 8.00 435.04 54.38
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 33 36.00 1016.90 28.25
AUDE-92588-OTOACOUSTIC EMISSIONS (COMP) 36 37.00 1151.54 31.12
AUDE-92682-CONDITIONED PLAY AUDIOMETRY 1 1.00 21.34 21.34
AUDE-V5010-ASSESSMENT FOR HEARING AID 3 3.00 140.40 46.80
AUDE-V5090-DISPENSING FEE PER HEARING AID 9 14.00 1232.02 88.00
BEHV-H0031HO-COMP BEHAVIORAL HEALTH ASSESSMENT 13 13.00 1525.00 117.31
EVAL-EVAL-DEVELOPMENTAL EVALUATION 85 95.00 4761.00 50.12
EXIT-EXIT-TRANSITION ASSESSMENT 412 686.00 34362.50 50.09
IPDEF-IPDEF_NM-F/U PSYCH & DEV EVAL BY NON-MED PROF 5 6.50 349.75 53.81
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 202 311.00 23211.25 74.63
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 76 110.00 8250.00 75.00
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 63 83.00 6225.00 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 137 197.50 14825.22 75.06
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 215 323.00 17893.25 55.40
IPDEI-IPDEI_NM-INITIAL PSYCH & DEV EVAL BY NON-MED PR 159 264.50 14200.00 53.69
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 2295 3314.54 245816.05 74.16
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 877 1388.59 104124.66 74.99
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 680 938.90 69843.54 74.39
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 2202 3462.00 192025.25 55.47
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 1353 2075.00 157262.50 75.79
MED-99202-OUTPATIENT VISIT, NEW, 20 MINS 2 2.00 54.44 27.22
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 154 155.00 26363.00 170.08
MED-99204-OUTPATIENT VISIT, NEW, 45 MINS 27 27.00 1981.75 73.40
MED-99205-OUTPATIENT VISIT, NEW, 60 MINS 7 7.00 509.46 72.78
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 35 35.00 3675.00 105.00
MED-99214-OUTPATIENT VISIT, EST, 25 MINS 1 1.00 160.00 160.00
MED-99215-OUTPATIENT VISIT, EST, 40 MINS 11 11.00 551.65 50.15
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 76 82.00 3922.94 47.84
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 248 255.40 12185.40 47.71
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 76 77.00 3675.75 47.74
PSTH-97001-EVAL BY LICENSED PT, INITIAL 163 177.87 8385.76 47.15
SCREEN-T1023-INTERDISCIPLINARY SCREENING 159 163.00 8150.00 50.00
SPCH-92506-SPEECH EVAL BY LICENSED SLP 555 575.00 27705.25 48.18
VISD-VISD-VISION EVALUATION DIAGNOSTIC 1 32.00 16.00 0.50
VISF-VISF-VISION EVALUATION FUNCTIONAL 4 4.00 900.00 225.00
Subtotal (Total Children Is Unduplicated) 5825 15822.8 1009162.31 63.78
----------------------------------------------------------------------------------------------------------------
EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 50 151.00 28985.28 191.96
AUD-92630-AUD REHAB PRELING HEARING LOSS 1 1.00 68.86 68.86
AUD-HA_FUP-AUDIOLOGY SERVICES 11 16.00 655.38 40.96
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 816 963.00 47967.50 49.81
COIFP-COIFP-IFSP CONSULT, PRO, BY PHONE 57 41.00 1025.00 25.00
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 1001 1556.75 77825.00 49.99
CONIP-CONIP-CONSULT, ITDS, PHONE 245 332.00 8305.00 25.02
CONOF-CONOF-CONSULT, OT, FACE TO FACE 256 256.50 12722.50 49.60
CONOP-CONOP-CONSULT, OT, PHONE 23 23.50 581.25 24.73
CONPF-CONPF-CONSULT, PT, FACE TO FACE 215 241.00 11945.00 49.56
CONPP-CONPP-CONSULT, PT, PHONE 18 9.75 243.75 25.00
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 970 1515.00 75677.50 49.95
CONSP-CONSP-CONSULT, SLP, PHONE 224 340.00 8481.25 24.94
COUN-H2019HR-INDIVIDUAL/FAMILY THERAPY 6 15.00 525.00 35.00
ECE-ECE-EARLY CHILDHOOD EDUCATION 91 7766.00 70139.00 9.03
EIGF-EIGF_NM-EI GROUP SESSION BY NONMED PROF 102 4574.00 114350.00 25.00
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 174 1974.00 49852.50 25.25
EIIF-90847-FAMILY PSYCHOTHERAPY WITH PATIENT 1 1.00 61.27 61.27
EIIF-96154-HEALTH AND BEHAVIOR INTERVENTION 50 402.75 20137.50 50.00
EIIF-EIIF_NM-EI INDIVIDUAL SESSION BY NONMED PROF 197 1052.50 50822.84 48.29
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 5368 38765.0 1922620.74 49.60
HERN-EIIF_NM-EI HEARING SERVICES AFTER SHINE NONMED 31 139.75 6987.50 50.00
HERN-T1027SC-EI HEARING SERVICES AFTER SHINE 25 78.75 3937.50 50.00
INTR-INTR-INTERPRETER 190 1019.00 41561.25 40.79
CMS/EIP Fiscal Report Statewide
Services beginning 07/01/2009 ending 09/30/2009 Date of Report:11/17/2009 Page: 2
Eligibility Filter:Program Patients
List order: No List
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
OCCT-97530-OT SESSION BY LICENSED OT 2074 11321.2 753690.11 66.57
OCCT-97530HM-OT SESSION BY OT ASST 97 312.00 17096.65 54.80
PHY-97110-PT SESSION BY LICENSED PT 2122 10435.6 691535.31 66.27
PHY-97110HM-PT SESSION BY PT ASST 81 350.00 19238.79 54.97
RSPT-RSPT-RESPITE 1 102.50 820.00 8.00
SENS-HA_EIP-ONE UNIT UP TO $500 PER AID 5 8.00 3149.96 393.75
SENS-V5050-MED HEARING AID - ANALOG/DIGITAL 1 2.00 798.00 399.00
SENS-V5264-EARMOLD 21 40.00 2023.20 50.58
SHIN-T1027SC-INITIAL SHINE SERVICES, INDIVIDUAL 31 48.25 2412.50 50.00
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 5103 28447.0 1902425.93 66.88
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 33 94.50 5062.48 53.57
SPL-92508-GROUP SPL SESSION PER CHILD 72 175.25 2730.69 15.58
TRAN-TRAN-FAMILY TRANSPORTATION 380 484.00 7987.93 16.50
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 9440 2016961 1059358.71 0.53
VISN-EIIF_NM-EI VISION SERVICES, IND NONMED 37 230.00 11500.00 50.00
VISN-T1027SC-EI VISION SERVICES, INDIVIDUAL 9 52.00 2600.00 50.00
Subtotal (Total Children Is Unduplicated) 12271 2130298 7037908.63 3.30
----------------------------------------------------------------------------------------------------------------
Total 2232552.89 10960412.19 4.91
----------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 21949
----------------------------------------------------------------------------------------------------------------
Center 01
Flag Claims Units Chgs Paid
-------------------------------------------------
R 0 0.00 0.00 0.00
U 0 0.00 0.00 0.00
B 3724 2616.75 101519.75 0.00
P 8521 155824.25 285570.13 285579.38
D 187 200.25 12140.63 0.00
S 1681 1415.25 52310.00 0.00
H 85 98.50 6733.00 0.00
T 5428 102173.00 185828.05 185828.05
8670 9501.00 296852.40 292.88
Other 641 6617.75 54172.45 67.88
-------------------------------------------------
Total 28937 278446.75 995126.41 471768.19
Center 02
Flag Claims Units Chgs Paid
-------------------------------------------------
R 85 58.00 2109.00 0.00
U 0 0.00 0.00 0.00
B 844 3339.75 128002.50 0.00
P 0 155824.25 285570.13 285579.38
D 0 200.25 12140.63 0.00
S 0 1415.25 52310.00 0.00
H 0 98.50 6733.00 0.00
T 1840 172533.25 272311.76 272311.76
1479 22763.75 355221.16 292.88
Other 0 6617.75 54172.45 67.88
-------------------------------------------------
Total 4248 362850.75 1168570.63 558251.90
Center 03
Flag Claims Units Chgs Paid
-------------------------------------------------
R 8 60.25 2192.25 0.00
U 0 0.00 0.00 0.00
B 70 3412.25 131463.50 37.00
P 6911 218632.00 515568.72 515392.97
D 0 200.25 12140.63 0.00
S 0 1415.25 52310.00 0.00
H 0 98.50 6733.00 0.00
T 3893 175284.25 359245.85 359245.85
4545 53396.00 494945.53 292.88
Other 113 6730.25 55978.19 67.88
-------------------------------------------------
Total 15540 459229.00 1630577.67 875036.58
Center 04
Flag Claims Units Chgs Paid
-------------------------------------------------
R 0 60.25 2192.25 0.00
U 0 0.00 0.00 0.00
B 1866 5299.00 210991.75 37.00
P 5707 353608.80 820900.64 819784.76
D 167 519.50 18660.28 6519.65
S 0 1415.25 52310.00 0.00
H 1491 5080.75 249698.55 242980.26
T 0 175284.25 359245.85 359245.85
6134 64352.00 851250.06 292.88
Other 0 6730.25 55978.19 67.88
-------------------------------------------------
Total 15365 612350.05 2621227.57 1428928.28
Center 05
Flag Claims Units Chgs Paid
-------------------------------------------------
R 0 60.25 2192.25 0.00
U 0 0.00 0.00 0.00
B 2649 6750.00 264704.90 37.00
P 3349 445487.76 978207.21 977091.33
D 0 519.50 18660.28 6519.65
S 0 1415.25 52310.00 0.00
H 0 5080.75 249698.55 242980.26
T 0 175284.25 359245.85 359245.85
7054 71339.98 1038613.85 292.88
Other 0 6730.25 55978.19 67.88
-------------------------------------------------
Total 13052 712667.99 3019611.08 1586234.85
Center 06
Flag Claims Units Chgs Paid
-------------------------------------------------
R 1 61.25 2229.25 0.00
U 0 0.00 0.00 0.00
B 4490 9732.50 375057.40 37.00
P 11303 579021.26 1289378.05 1288262.17
D 0 519.50 18660.28 6519.65
S 0 1415.25 52310.00 0.00
H 0 5080.75 249698.55 242980.26
T 0 175284.25 359245.85 359245.85
14272 107936.48 1515076.02 292.88
Other 0 6730.25 55978.19 67.88
-------------------------------------------------
Total 30066 885781.49 3917633.59 1897405.69
Center 07
Flag Claims Units Chgs Paid
-------------------------------------------------
R 13 66.75 2432.75 0.00
U 0 0.00 0.00 0.00
B 2924 11644.50 450127.40 37.00
P 5427 706467.51 1694333.95 1693294.57
D 0 519.50 18660.28 6519.65
S 11 1422.75 52700.50 0.00
H 0 5080.75 249698.55 242980.26
T 0 175284.25 359245.85 359245.85
9592 120658.73 1899396.75 292.88
Other 0 6730.25 55978.19 67.88
-------------------------------------------------
Total 17967 1027874.99 4782574.22 2302438.09
Center 09
Flag Claims Units Chgs Paid
-------------------------------------------------
R 15 82.75 3061.75 27.75
U 0 0.00 0.00 0.00
B 1024 12628.00 500305.04 372.00
P 11447 849483.26 2257427.72 2260038.27
D 0 519.50 18660.28 6519.65
S 0 1422.75 52700.50 0.00
H 1 5081.25 249717.05 242998.76
T 4866 257291.50 624909.51 624909.51
3657 132386.48 2324414.93 2282.63
Other 0 6730.25 55978.19 67.88
-------------------------------------------------
Total 21010 1265625.74 6087174.97 3137216.45
Center 10
Flag Claims Units Chgs Paid
-------------------------------------------------
R 46 130.25 4998.00 27.75
U 0 0.00 0.00 0.00
B 3085 14664.25 576886.04 372.00
P 8806 973261.51 2757464.01 2759904.56
D 29 538.25 19467.03 7326.40
S 469 1701.50 63014.25 0.00
H 0 5081.25 249717.05 242998.76
T 0 257291.50 624909.51 624909.51
11747 144710.48 2911599.05 2282.63
Other 0 6730.25 55978.19 67.88
-------------------------------------------------
Total 24182 1404109.24 7264033.13 3637889.49
Center 51
Flag Claims Units Chgs Paid
-------------------------------------------------
R 10 135.25 5259.00 27.75
U 0 0.00 0.00 0.00
B 3731 17396.50 680076.70 372.00
P 2327 1093828.76 2934955.83 2937396.38
D 16 550.50 19938.78 7326.40
S 0 1701.50 63014.25 0.00
H 0 5081.25 249717.05 242998.76
T 0 257291.50 624909.51 624909.51
5159 151329.23 3197450.16 2282.63
Other 0 6730.25 55978.19 67.88
-------------------------------------------------
Total 11243 1534044.74 7831299.47 3815381.31
Center 52
Flag Claims Units Chgs Paid
-------------------------------------------------
R 17 151.50 6401.13 27.75
U 0 0.00 0.00 0.00
B 2553 19069.50 754156.42 372.00
P 566 1123750.04 2973665.63 2976106.18
D 0 550.50 19938.78 7326.40
S 42 1742.75 64842.75 0.00
H 98 5268.75 261353.55 242998.76
T 0 257291.50 624909.51 624909.51
7159 246062.46 3536456.69 2282.63
Other 0 6730.25 55978.19 67.88
-------------------------------------------------
Total 10435 1660617.25 8297702.65 3854091.11
Center 53
Flag Claims Units Chgs Paid
-------------------------------------------------
R 18 171.25 7417.63 27.75
U 0 0.00 0.00 0.00
B 805 19801.50 782798.42 372.00
P 1792 1142915.00 3063770.25 3066234.36
D 11 566.50 20833.28 7326.40
S 0 1742.75 64842.75 0.00
H 0 5268.75 261353.55 242998.76
T 1862 291306.93 686618.69 686618.69
6718 298808.51 3797363.89 3082.63
Other 0 6730.25 55978.19 67.88
-------------------------------------------------
Total 11206 1767311.44 8740976.65 4006728.47
Center 54
Flag Claims Units Chgs Paid
-------------------------------------------------
R 32 205.50 9241.13 27.75
U 0 0.00 0.00 0.00
B 89 19878.50 786027.17 372.00
P 7547 1311602.28 3519926.36 3522166.10
D 182 710.00 26683.28 7326.40
S 1 1743.75 64892.75 0.00
H 0 5268.75 261353.55 242998.76
T 1 291307.18 686627.94 686618.69
5891 333475.75 4109966.08 3082.63
Other 1 6730.50 55987.44 67.88
-------------------------------------------------
Total 13744 1970922.21 9520705.70 4462660.21
Center 55
Flag Claims Units Chgs Paid
-------------------------------------------------
R 0 205.50 9241.13 27.75
U 0 0.00 0.00 0.00
B 9 19885.00 786267.67 372.00
P 5302 1369974.14 3693165.40 3695205.14
D 43 754.50 28842.78 7326.40
S 3 1747.75 65040.75 0.00
H 16 5292.75 265353.55 242998.76
T 0 291307.18 686627.94 686618.69
5785 348933.82 4329577.95 3082.63
Other 11 6739.75 56329.69 67.88
-------------------------------------------------
Total 11169 2044840.39 9920446.86 4635699.25
Center 57
Flag Claims Units Chgs Paid
-------------------------------------------------
R 26 234.75 10823.13 27.75
U 0 0.00 0.00 0.00
B 541 20470.50 808427.92 372.00
P 1228 1371274.89 3746119.90 3748159.64
D 20 778.25 29721.53 7326.40
S 125 4896.25 71788.75 6887.00
H 1 5293.25 265372.05 243017.26
T 6934 455955.68 1154635.41 1155529.93
5818 366896.07 4816366.83 234452.77
Other 10 6753.25 57156.67 894.86
-------------------------------------------------
Total 14703 2232552.8910960412.19 5396667.61