CMS/EIP Fiscal Report Statewide
Services beginning 07/01/2009 ending 09/30/2009 Date of Report:11/17/2009 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 6879 4506.50 166675.75 36.99
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 5907 6786.00 0.00 0.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 6305 6984.75 258269.25 36.98
TCM-T1017TL-TARGETED CASE MANAGEMENT 9690 30287.8 1119768.00 36.97
TCON-TCON-TRANSITION CONFERENCE 826 829.00 0.00 0.00
Subtotal (Total Children Is Unduplicated) 16368 49394.0 1544713.00 31.27
----------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
ASTE-ASTE-ASSISTIVE TECHNOLOGY EVAL 17 16.91 749.51 44.32
AUD-92626-EVAL OF AUD REHAB STATUS 1 1.00 36.07 36.07
AUDE-92552-PURE TONE AUDIOMETRY -AIR ONLY 26 28.00 291.12 10.40
AUDE-92553-PURE TONE AUDIOMETRY AIR & BONE 3 3.00 47.60 15.87
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 54 57.00 491.82 8.63
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 75 79.00 831.52 10.53
AUDE-92568-ACOUSTIC REFLEX TESTING (MEMR) 3 3.00 18.44 6.15
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 72 75.00 1582.93 21.11
AUDE-92585-AUD EVOKED RESPONSE (DIAG) 1 1.00 54.38 54.38
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 22 25.00 705.82 28.23
AUDE-92588-OTOACOUSTIC EMISSIONS (COMP) 5 6.00 165.43 27.57
AUDE-92682-CONDITIONED PLAY AUDIOMETRY 1 1.00 21.34 21.34
AUDE-V5010-ASSESSMENT FOR HEARING AID 2 2.00 93.60 46.80
AUDE-V5090-DISPENSING FEE PER HEARING AID 8 10.00 957.17 95.72
BEHV-H0031HO-COMP BEHAVIORAL HEALTH ASSESSMENT 13 13.00 1525.00 117.31
EVAL-EVAL-DEVELOPMENTAL EVALUATION 84 91.00 4561.00 50.12
EXIT-EXIT-TRANSITION ASSESSMENT 411 680.75 34100.00 50.09
IPDEF-IPDEF_NM-F/U PSYCH & DEV EVAL BY NON-MED PROF 3 3.50 183.25 52.36
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 51 76.50 5697.75 74.48
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 19 27.50 2062.50 75.00
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 14 14.50 1087.50 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 51 47.17 3537.72 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 54 82.50 4545.50 55.10
IPDEI-IPDEI_NM-INITIAL PSYCH & DEV EVAL BY NON-MED PR 141 234.28 12493.06 53.33
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 742 1085.29 80027.13 73.74
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 225 372.80 27894.60 74.82
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 166 236.84 17465.37 73.74
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 871 1409.11 78197.58 55.49
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 498 730.61 54345.34 74.38
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 14 14.00 1867.50 133.39
MED-99204-OUTPATIENT VISIT, NEW, 45 MINS 4 4.00 229.08 57.27
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 35 34.39 1613.69 46.92
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 92 91.63 4224.05 46.10
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 19 19.00 862.75 45.41
PSTH-97001-EVAL BY LICENSED PT, INITIAL 67 77.35 3549.26 45.89
SCREEN-T1023-INTERDISCIPLINARY SCREENING 61 62.00 3100.00 50.00
SPCH-92506-SPEECH EVAL BY LICENSED SLP 266 267.83 12798.12 47.78
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) 2644 6019.46 362930.50 60.29
----------------------------------------------------------------------------------------------------------------
EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 41 112.00 20385.84 182.02
AUD-92630-AUD REHAB PRELING HEARING LOSS 1 1.00 68.86 68.86
AUD-HA_FUP-AUDIOLOGY SERVICES 10 13.00 576.85 44.37
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 806 950.50 47342.50 49.81
COIFP-COIFP-IFSP CONSULT, PRO, BY PHONE 57 41.00 1025.00 25.00
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 988 1544.75 77225.00 49.99
CONIP-CONIP-CONSULT, ITDS, PHONE 242 330.75 8268.75 25.00
CONOF-CONOF-CONSULT, OT, FACE TO FACE 255 253.50 12572.50 49.60
CONOP-CONOP-CONSULT, OT, PHONE 21 22.75 562.50 24.73
CONPF-CONPF-CONSULT, PT, FACE TO FACE 214 240.00 11895.00 49.56
CONPP-CONPP-CONSULT, PT, PHONE 18 9.50 237.50 25.00
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 955 1486.75 74265.00 49.95
CONSP-CONSP-CONSULT, SLP, PHONE 223 339.00 8456.25 24.94
COUN-H2019HR-INDIVIDUAL/FAMILY THERAPY 6 15.00 525.00 35.00
ECE-ECE-EARLY CHILDHOOD EDUCATION 1 70.00 875.00 12.50
EIGF-EIGF_NM-EI GROUP SESSION BY NONMED PROF 1 1.00 25.00 25.00
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 72 316.00 8402.50 26.59
EIIF-90847-FAMILY PSYCHOTHERAPY WITH PATIENT 1 1.00 61.27 61.27
EIIF-96154-HEALTH AND BEHAVIOR INTERVENTION 48 377.75 18887.50 50.00
EIIF-EIIF_NM-EI INDIVIDUAL SESSION BY NONMED PROF 96 592.50 29277.68 49.41
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 2545 18576.0 926703.61 49.89
HERN-EIIF_NM-EI HEARING SERVICES AFTER SHINE NONMED 24 110.50 5525.00 50.00
HERN-T1027SC-EI HEARING SERVICES AFTER SHINE 9 28.00 1400.00 50.00
INTR-INTR-INTERPRETER 190 1017.00 41473.25 40.78
OCCT-97530-OT SESSION BY LICENSED OT 938 4909.82 312802.16 63.71
OCCT-97530HM-OT SESSION BY OT ASST 35 95.25 5162.94 54.20
PHY-97110-PT SESSION BY LICENSED PT 858 4010.58 255237.97 63.64
PHY-97110HM-PT SESSION BY PT ASST 9 14.51 765.42 52.75
RSPT-RSPT-RESPITE 1 102.50 820.00 8.00
CMS/EIP Fiscal Report Statewide
Services beginning 07/01/2009 ending 09/30/2009 Date of Report:11/17/2009 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-HA_EIP-ONE UNIT UP TO $500 PER AID 4 6.00 2849.96 474.99
SENS-V5050-MED HEARING AID - ANALOG/DIGITAL 1 2.00 798.00 399.00
SENS-V5264-EARMOLD 14 27.00 502.56 18.61
SHIN-T1027SC-INITIAL SHINE SERVICES, INDIVIDUAL 14 18.00 900.00 50.00
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 3046 17255.0 1133306.24 65.68
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 16 32.00 1721.80 53.81
SPL-92508-GROUP SPL SESSION PER CHILD 36 117.50 1675.11 14.26
TRAN-TRAN-FAMILY TRANSPORTATION 380 484.00 7987.93 16.50
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 9418 2012994 1056019.01 0.52
VISN-EIIF_NM-EI VISION SERVICES, IND NONMED 27 132.75 6637.50 50.00
VISN-T1027SC-EI VISION SERVICES, INDIVIDUAL 6 24.00 1200.00 50.00
Subtotal (Total Children Is Unduplicated) 11223 2066674 4084423.96 1.98
----------------------------------------------------------------------------------------------------------------
Total 2122087.72 5992067.46 2.82
----------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 19120
----------------------------------------------------------------------------------------------------------------
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 7918 155429.25 270842.13 270842.13
D 25 30.00 1969.88 0.00
S 508 449.75 16631.50 0.00
H 1 0.50 37.50 0.00
T 5428 102173.00 185828.05 185828.05
7261 6949.55 172144.65 0.00
Other 225 5951.75 12991.35 0.00
-------------------------------------------------
Total 21366 270983.80 660445.06 456670.18
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 155429.25 270842.13 270842.13
D 0 30.00 1969.88 0.00
S 0 449.75 16631.50 0.00
H 0 0.50 37.50 0.00
T 1840 172533.25 272311.76 272311.76
1345 19968.80 215957.91 0.00
Other 0 5951.75 12991.35 0.00
-------------------------------------------------
Total 3185 354363.30 790742.03 543153.89
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 4584 216595.00 435562.22 435562.22
D 0 30.00 1969.88 0.00
S 0 449.75 16631.50 0.00
H 0 0.50 37.50 0.00
T 3893 175284.25 359245.85 359245.85
4187 50327.55 345667.69 0.00
Other 0 5951.75 12991.35 0.00
-------------------------------------------------
Total 12664 448638.80 1172105.99 794808.07
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 2590 348456.30 621412.64 621510.21
D 163 341.50 8150.78 6180.90
S 0 449.75 16631.50 0.00
H 76 573.00 12431.48 11828.38
T 0 175284.25 359245.85 359245.85
5214 54335.05 477503.44 0.00
Other 0 5951.75 12991.35 0.00
-------------------------------------------------
Total 8043 585391.60 1508367.04 998765.34
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 3117 439590.51 758962.78 759060.35
D 0 341.50 8150.78 6180.90
S 0 449.75 16631.50 0.00
H 0 573.00 12431.48 11828.38
T 0 175284.25 359245.85 359245.85
4620 59686.10 566255.59 0.00
Other 0 5951.75 12991.35 0.00
-------------------------------------------------
Total 7737 681876.86 1734669.33 1136315.48
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 11303 573124.01 1070133.62 1070231.19
D 0 341.50 8150.78 6180.90
S 0 449.75 16631.50 0.00
H 0 573.00 12431.48 11828.38
T 0 175284.25 359245.85 359245.85
8986 91765.85 759840.39 0.00
Other 0 5951.75 12991.35 0.00
-------------------------------------------------
Total 20289 847490.11 2239424.97 1447486.32
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 3311 699007.76 1405085.31 1405182.88
D 0 341.50 8150.78 6180.90
S 1 450.00 16640.75 0.00
H 0 573.00 12431.48 11828.38
T 0 175284.25 359245.85 359245.85
8231 100769.60 935784.37 0.00
Other 0 5951.75 12991.35 0.00
-------------------------------------------------
Total 11543 982377.86 2750329.89 1782438.01
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 8636 839507.01 1849142.24 1849181.93
D 0 341.50 8150.78 6180.90
S 0 450.00 16640.75 0.00
H 0 573.00 12431.48 11828.38
T 4866 257291.50 624909.51 624909.51
502 106422.35 971369.42 1989.75
Other 0 5951.75 12991.35 0.00
-------------------------------------------------
Total 14004 1210537.11 3495635.53 2494090.47
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 0.50 18.50 0.00
P 4365 959876.51 2193913.28 2193952.97
D 29 360.25 8957.53 6987.65
S 1 450.25 16650.00 0.00
H 0 573.00 12431.48 11828.38
T 0 257291.50 624909.51 624909.51
8532 112868.35 1189084.17 1989.75
Other 0 5951.75 12991.35 0.00
-------------------------------------------------
Total 12928 1337372.11 4058955.82 2839668.26
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 0.50 18.50 0.00
P 2288 1080047.76 2362374.14 2362413.83
D 16 372.50 9429.28 6987.65
S 0 450.25 16650.00 0.00
H 0 573.00 12431.48 11828.38
T 0 257291.50 624909.51 624909.51
3863 116393.35 1287999.71 1989.75
Other 0 5951.75 12991.35 0.00
-------------------------------------------------
Total 6167 1461080.61 4326803.97 3008129.12
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 0.50 18.50 0.00
P 566 1109969.04 2401083.94 2401123.63
D 0 372.50 9429.28 6987.65
S 1 450.75 16668.50 0.00
H 0 573.00 12431.48 11828.38
T 0 257291.50 624909.51 624909.51
5843 207566.77 1461692.89 1989.75
Other 0 5951.75 12991.35 0.00
-------------------------------------------------
Total 6410 1582175.81 4539225.45 3046838.92
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 0.50 18.50 0.00
P 624 1127894.14 2428873.21 2428940.14
D 7 382.50 9964.28 6987.65
S 0 450.75 16668.50 0.00
H 0 573.00 12431.48 11828.38
T 1862 291306.93 686618.69 686618.69
3653 257617.53 1580690.12 1989.75
Other 0 5951.75 12991.35 0.00
-------------------------------------------------
Total 6146 1684177.10 4748256.13 3136364.61
Center 54
Flag Claims Units Chgs Paid
-------------------------------------------------
R 0 0.00 0.00 0.00
U 0 0.00 0.00 0.00
B 1 2.00 64.75 0.00
P 3302 1293516.67 2760703.44 2760770.37
D 182 526.00 15814.28 6987.65
S 0 450.75 16668.50 0.00
H 0 573.00 12431.48 11828.38
T 0 291306.93 686618.69 686618.69
4372 288314.25 1707639.59 1989.75
Other 0 5951.75 12991.35 0.00
-------------------------------------------------
Total 7857 1880641.35 5212932.08 3468194.84
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 2.00 64.75 0.00
P 3788 1350479.78 2878064.57 2878131.50
D 43 570.50 17973.78 6987.65
S 0 450.75 16668.50 0.00
H 0 573.00 12431.48 11828.38
T 0 291306.93 686618.69 686618.69
2717 301354.01 1770297.80 1989.75
Other 0 5951.75 12991.35 0.00
-------------------------------------------------
Total 6548 1950688.72 5395110.92 3585555.97
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 2.00 64.75 0.00
P 0 1350479.78 2878064.57 2878131.50
D 20 594.25 18852.53 6987.65
S 125 3599.25 23416.50 6887.00
H 0 573.00 12431.48 11828.38
T 6909 455910.93 1151882.28 1152786.05
3533 304976.76 1894364.00 2829.15
Other 0 5951.75 12991.35 0.00
-------------------------------------------------
Total 10587 2122087.72 5992067.46 4059449.73