CMS/EIP Fiscal Report Statewide
Services beginning 10/01/2009 ending 12/31/2009 Date of Report:02/16/2010 Page: 1
Agency Filter:EXT
Payclass Filters:GR
Eligibility Filter:Part C (excluding not eligible)
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 27 74.75 2765.75 37.00
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 10 10.00 0.00 0.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 72 107.00 3959.00 37.00
TCON-TCON-TRANSITION CONFERENCE 1 1.00 0.00 0.00
Subtotal (Total Children Is Unduplicated) 106 192.75 6724.75 34.89
----------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
ASTE-ASTE-ASSISTIVE TECHNOLOGY EVAL 10 13.00 607.00 46.69
AUDE-92552-PURE TONE AUDIOMETRY -AIR ONLY 15 16.00 169.92 10.62
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 21 22.00 194.26 8.83
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 35 36.00 371.40 10.32
AUDE-92568-ACOUSTIC REFLEX TESTING (MEMR) 2 2.00 16.88 8.44
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 32 33.00 719.07 21.79
AUDE-92585-AUD EVOKED RESPONSE (DIAG) 1 1.00 54.38 54.38
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 24 24.29 664.47 27.36
AUDE-92588-OTOACOUSTIC EMISSIONS (COMP) 4 4.00 127.24 31.81
AUDE-V5010-ASSESSMENT FOR HEARING AID 2 2.00 93.60 46.80
AUDE-V5090-DISPENSING FEE PER HEARING AID 5 7.00 732.37 104.62
BEHV-H0031HO-COMP BEHAVIORAL HEALTH ASSESSMENT 9 9.00 1050.00 116.67
EVAL-EVAL-DEVELOPMENTAL EVALUATION 14 21.00 1050.00 50.00
EXIT-EXIT-TRANSITION ASSESSMENT 199 376.50 18825.00 50.00
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 20 26.82 2010.86 74.98
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 4 6.50 487.50 75.00
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 4 3.50 262.50 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 7 10.00 750.00 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 10 16.50 915.75 55.50
IPDEI-IPDEI_NM-INITIAL PSYCH & DEV EVAL BY NON-MED PR 21 22.50 1072.00 47.64
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 147 225.35 16464.73 73.06
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 74 127.34 9436.32 74.10
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 23 31.00 2132.69 68.80
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 104 182.50 10109.50 55.39
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 80 110.00 8175.00 74.32
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 30 31.00 1318.09 42.52
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 82 82.37 3871.45 47.00
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 22 21.75 1031.46 47.42
PSTH-97001-EVAL BY LICENSED PT, INITIAL 57 56.25 2573.05 45.74
SPCH-92506-SPEECH EVAL BY LICENSED SLP 230 237.31 11310.45 47.66
Subtotal (Total Children Is Unduplicated) 977 1757.48 96596.94 54.96
----------------------------------------------------------------------------------------------------------------
EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 34 75.00 12542.19 167.23
AUD-92630-AUD REHAB PRELING HEARING LOSS 1 3.00 206.58 68.86
AUD-HA_FUP-AUDIOLOGY SERVICES 7 10.00 422.23 42.22
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 558 657.00 31625.00 48.14
COIFP-COIFP-IFSP CONSULT, PRO, BY PHONE 13 6.25 137.50 22.00
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 940 1545.50 74800.00 48.40
CONIP-CONIP-CONSULT, ITDS, PHONE 164 188.50 4693.75 24.90
CONOF-CONOF-CONSULT, OT, FACE TO FACE 213 220.25 11012.50 50.00
CONOP-CONOP-CONSULT, OT, PHONE 21 14.50 362.50 25.00
CONPF-CONPF-CONSULT, PT, FACE TO FACE 175 189.00 9412.50 49.80
CONPP-CONPP-CONSULT, PT, PHONE 17 10.25 256.25 25.00
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 871 1282.75 64137.50 50.00
CONSP-CONSP-CONSULT, SLP, PHONE 151 168.25 4206.25 25.00
COUN-H2019HR-INDIVIDUAL/FAMILY THERAPY 2 4.00 140.00 35.00
ECE-ECE-EARLY CHILDHOOD EDUCATION 1 54.40 680.00 12.50
EIGF-EIGF_NM-EI GROUP SESSION BY NONMED PROF 11 31.00 665.96 21.48
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 58 261.00 7024.88 26.92
EIIF-90847-FAMILY PSYCHOTHERAPY WITH PATIENT 1 5.00 306.35 61.27
EIIF-96154-HEALTH AND BEHAVIOR INTERVENTION 44 350.50 17100.00 48.79
EIIF-EIIF_NM-EI INDIVIDUAL SESSION BY NONMED PROF 79 376.25 16417.82 43.64
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 2301 16857.8 836896.25 49.64
HERN-T1027SC-EI HEARING SERVICES AFTER SHINE 2 11.00 550.00 50.00
INTR-INTR-INTERPRETER 143 925.25 37006.50 40.00
OCCT-97530-OT SESSION BY LICENSED OT 869 4709.87 305319.30 64.83
OCCT-97530HM-OT SESSION BY OT ASST 28 93.95 4915.38 52.32
PHY-97110-PT SESSION BY LICENSED PT 822 3914.60 251373.39 64.21
PHY-97110HM-PT SESSION BY PT ASST 13 35.96 1914.87 53.25
RSPT-RSPT-RESPITE 1 77.50 620.00 8.00
SENS-HA_EIP-ONE UNIT UP TO $500 PER AID 2 4.00 2000.00 500.00
SENS-HA_INS-SENSORY AID INSURANCE PER EAR 2 4.00 260.00 65.00
SENS-V5050-MED HEARING AID - ANALOG/DIGITAL 1 2.00 798.00 399.00
SENS-V5264-EARMOLD 6 11.00 203.04 18.46
SHIN-T1027SC-INITIAL SHINE SERVICES, INDIVIDUAL 8 9.50 475.00 50.00
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 2806 16227.5 1067856.07 65.81
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 20 54.50 2840.17 52.11
SPL-92508-GROUP SPL SESSION PER CHILD 20 44.25 582.08 13.15
TRAN-TRAN-FAMILY TRANSPORTATION 6 479.00 429.01 0.90
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 8329 1802768 946848.09 0.53
VISN-EIIF_NM-EI VISION SERVICES, IND NONMED 1 1.00 50.00 50.00
CMS/EIP Fiscal Report Statewide
Services beginning 10/01/2009 ending 12/31/2009 Date of Report:02/16/2010 Page: 2
Agency Filter:EXT
Payclass Filters:GR
Eligibility Filter:Part C (excluding not eligible)
List order: No List
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
VISN-T1027SC-EI VISION SERVICES, INDIVIDUAL 7 15.00 750.00 50.00
Subtotal (Total Children Is Unduplicated) 9785 1851698 3717836.91 2.01
----------------------------------------------------------------------------------------------------------------
Total 1853648.29 3821158.60 2.06
----------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 10004
----------------------------------------------------------------------------------------------------------------
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 5760 154609.00 222875.99 222925.99
D 4 4.00 200.00 0.00
S 0 0.00 0.00 0.00
H 0 0.00 0.00 0.00
T 3560 98595.00 160957.32 160957.32
304 4424.25 18475.92 0.00
Other 412 9418.75 18425.28 0.00
-------------------------------------------------
Total 10040 267051.00 420934.51 383883.31
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 154609.00 222875.99 222925.99
D 0 4.00 200.00 0.00
S 0 0.00 0.00 0.00
H 0 0.00 0.00 0.00
T 875 144532.25 221555.27 221555.27
712 37580.50 64446.44 0.00
Other 0 9418.75 18425.28 0.00
-------------------------------------------------
Total 1587 346144.50 527502.98 444481.26
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 2301 188584.25 311468.04 311518.04
D 0 4.00 200.00 0.00
S 0 0.00 0.00 0.00
H 0 0.00 0.00 0.00
T 0 144532.25 221555.27 221555.27
4659 105254.75 246877.48 0.00
Other 0 9418.75 18425.28 0.00
-------------------------------------------------
Total 6960 447794.00 798526.07 533073.31
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 2234 314236.50 494043.67 487608.91
D 1 68.00 232.00 32.00
S 0 0.00 0.00 0.00
H 243 13742.00 9240.22 8901.32
T 0 144532.25 221555.27 221555.27
284 105409.75 252612.48 0.00
Other 0 9418.75 18425.28 0.00
-------------------------------------------------
Total 2762 587407.25 996108.92 718097.50
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 1501 354698.77 556107.22 549672.46
D 0 68.00 232.00 32.00
S 0 0.00 0.00 0.00
H 0 13742.00 9240.22 8901.32
T 0 144532.25 221555.27 221555.27
2324 164952.57 355682.33 0.00
Other 0 9418.75 18425.28 0.00
-------------------------------------------------
Total 3825 687412.34 1161242.32 780161.05
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 4570 415640.77 674884.42 668481.78
D 0 68.00 232.00 32.00
S 0 0.00 0.00 0.00
H 0 13742.00 9240.22 8901.32
T 0 144532.25 221555.27 221555.27
6906 244823.32 543650.14 131.19
Other 0 9418.75 18425.28 0.00
-------------------------------------------------
Total 11476 828225.09 1467987.33 899101.56
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 3328 529257.77 1003377.62 996954.98
D 0 68.00 232.00 32.00
S 0 0.00 0.00 0.00
H 0 13742.00 9240.22 8901.32
T 0 144532.25 221555.27 221555.27
0 244823.32 543650.14 131.19
Other 0 9418.75 18425.28 0.00
-------------------------------------------------
Total 3328 941842.09 1796480.53 1227574.76
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 3165 661600.77 1351964.97 1345552.05
D 0 68.00 232.00 32.00
S 0 0.00 0.00 0.00
H 0 13742.00 9240.22 8901.32
T 1626 214468.25 413244.85 413244.85
431 253077.82 568327.21 429.57
Other 0 9418.75 18425.28 0.00
-------------------------------------------------
Total 5222 1152375.59 2361434.53 1768159.79
Center 10
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 3852 771967.77 1655335.24 1648922.32
D 0 68.00 232.00 32.00
S 0 0.00 0.00 0.00
H 0 13742.00 9240.22 8901.32
T 0 214468.25 413244.85 413244.85
0 253077.82 568327.21 429.57
Other 0 9418.75 18425.28 0.00
-------------------------------------------------
Total 3852 1262742.59 2664804.80 2071530.06
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 0.00 0.00 0.00
P 2111 868518.77 1810872.66 1804459.74
D 0 68.00 232.00 32.00
S 0 0.00 0.00 0.00
H 0 13742.00 9240.22 8901.32
T 0 214468.25 413244.85 413244.85
15 253096.07 569612.89 429.57
Other 0 9418.75 18425.28 0.00
-------------------------------------------------
Total 2126 1359311.84 2821627.90 2227067.48
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 0.00 0.00 0.00
P 741 905801.75 1861533.56 1855120.64
D 0 68.00 232.00 32.00
S 0 0.00 0.00 0.00
H 0 13742.00 9240.22 8901.32
T 0 214468.25 413244.85 413244.85
979 305526.62 636909.94 429.57
Other 0 9418.75 18425.28 0.00
-------------------------------------------------
Total 1720 1449025.37 2939585.85 2277728.38
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 0.00 0.00 0.00
P 0 905801.75 1861533.56 1855120.64
D 0 68.00 232.00 32.00
S 0 0.00 0.00 0.00
H 621 31449.00 35527.79 35188.89
T 749 233425.47 445567.69 445543.69
730 327802.02 669681.46 429.57
Other 0 9418.75 18425.28 0.00
-------------------------------------------------
Total 2100 1507964.99 3030967.78 2336314.79
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 0.00 0.00 0.00
P 2675 1046413.24 2140190.05 2133777.13
D 0 68.00 232.00 32.00
S 0 0.00 0.00 0.00
H 0 31449.00 35527.79 35188.89
T 0 233425.47 445567.69 445543.69
38 330560.72 674141.20 429.57
Other 0 9418.75 18425.28 0.00
-------------------------------------------------
Total 2713 1651335.18 3314084.01 2614971.28
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 0.00 0.00 0.00
P 2527 1084914.34 2212417.28 2206004.36
D 0 68.00 232.00 32.00
S 0 0.00 0.00 0.00
H 0 31449.00 35527.79 35188.89
T 963 249061.57 474178.95 474154.95
985 345544.74 700921.24 429.57
Other 0 9418.75 18425.28 0.00
-------------------------------------------------
Total 4475 1720456.40 3441702.54 2715809.77
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 0.00 0.00 0.00
P 0 1084914.34 2212417.28 2206004.36
D 0 68.00 232.00 32.00
S 197 3883.50 9360.90 9360.90
H 0 31449.00 35527.79 35188.89
T 5403 378308.96 843254.86 843572.56
27 345568.74 701847.99 679.57
Other 4 9455.75 18517.78 92.50
-------------------------------------------------
Total 5631 1853648.29 3821158.60 3094930.78