CMS/EIP Fiscal Report Statewide
Services beginning 10/01/2009 ending 12/31/2009 Date of Report:02/16/2010 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 7445 4716.75 174492.00 36.99
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 5667 6530.00 0.00 0.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 6426 7170.50 262515.00 36.61
TCM-T1017TL-TARGETED CASE MANAGEMENT 20051 63831.0 2359149.25 36.96
TCON-TCON-TRANSITION CONFERENCE 1009 1090.00 0.00 0.00
Subtotal (Total Children Is Unduplicated) 20645 83338.3 2796156.25 33.55
----------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
ASTE-ASTE-ASSISTIVE TECHNOLOGY EVAL 12 16.00 729.00 45.56
AUDE-92552-PURE TONE AUDIOMETRY -AIR ONLY 27 28.00 297.36 10.62
AUDE-92553-PURE TONE AUDIOMETRY AIR & BONE 4 4.00 65.20 16.30
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 214 217.00 1916.11 8.83
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 198 204.00 2182.86 10.70
AUDE-92568-ACOUSTIC REFLEX TESTING (MEMR) 9 9.00 75.96 8.44
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 220 225.00 4902.75 21.79
AUDE-92585-AUD EVOKED RESPONSE (DIAG) 5 5.00 271.90 54.38
AUDE-92586-AUD EVOKED RESPONSE (SCREEN) 2 2.00 60.86 30.43
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 38 40.00 1108.93 27.72
AUDE-92588-OTOACOUSTIC EMISSIONS (COMP) 21 24.00 740.46 30.85
AUDE-V5010-ASSESSMENT FOR HEARING AID 2 2.00 93.60 46.80
AUDE-V5090-DISPENSING FEE PER HEARING AID 6 10.00 952.20 95.22
BEHV-H0031HO-COMP BEHAVIORAL HEALTH ASSESSMENT 9 10.00 1175.00 117.50
EVAL-EVAL-DEVELOPMENTAL EVALUATION 89 102.00 5025.00 49.26
EXIT-EXIT-TRANSITION ASSESSMENT 532 837.25 41912.50 50.06
IPDEF-IPDEF_NM-F/U PSYCH & DEV EVAL BY NON-MED PROF 6 12.00 666.00 55.50
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 166 249.50 18587.50 74.50
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 56 85.50 6412.50 75.00
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 57 77.50 5812.50 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 125 202.00 15150.00 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 169 250.00 13875.00 55.50
IPDEI-IPDEI_NM-INITIAL PSYCH & DEV EVAL BY NON-MED PR 115 185.50 10229.32 55.14
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 2027 2937.24 218220.88 74.29
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 838 1356.00 101231.08 74.65
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 615 852.00 63688.51 74.75
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 2089 3340.44 185834.21 55.63
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 1217 1910.00 143461.02 75.11
MED-99202-OUTPATIENT VISIT, NEW, 20 MINS 2 2.00 54.44 27.22
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 147 148.00 25935.00 175.24
MED-99204-OUTPATIENT VISIT, NEW, 45 MINS 28 28.00 2256.75 80.60
MED-99205-OUTPATIENT VISIT, NEW, 60 MINS 10 10.00 727.80 72.78
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 24 24.00 2520.00 105.00
MED-99214-OUTPATIENT VISIT, EST, 25 MINS 1 1.00 160.00 160.00
MED-99215-OUTPATIENT VISIT, EST, 40 MINS 6 6.00 300.90 50.15
NUTR-97802-NUTRITIONAL EVAL, INITIAL 1 0.75 37.50 50.00
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 57 58.00 2627.59 45.30
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 200 205.00 9799.10 47.80
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 41 41.00 1966.94 47.97
PSTH-97001-EVAL BY LICENSED PT, INITIAL 141 144.00 6829.34 47.43
SCREEN-T1023-INTERDISCIPLINARY SCREENING 110 112.00 5600.00 50.00
SPCH-92506-SPEECH EVAL BY LICENSED SLP 493 518.00 24910.82 48.09
VISF-VISF-VISION EVALUATION FUNCTIONAL 1 0.50 25.00 50.00
Subtotal (Total Children Is Unduplicated) 5435 14491.2 928429.39 64.07
----------------------------------------------------------------------------------------------------------------
EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 46 115.00 19686.09 171.18
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 798 984.50 47975.00 48.73
COIFP-COIFP-IFSP CONSULT, PRO, BY PHONE 66 41.00 1006.25 24.54
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 997 1634.50 79250.00 48.49
CONIP-CONIP-CONSULT, ITDS, PHONE 175 199.50 4968.75 24.91
CONOF-CONOF-CONSULT, OT, FACE TO FACE 229 255.25 12762.50 50.00
CONOP-CONOP-CONSULT, OT, PHONE 27 18.00 450.00 25.00
CONPF-CONPF-CONSULT, PT, FACE TO FACE 203 224.25 11175.00 49.83
CONPP-CONPP-CONSULT, PT, PHONE 17 10.25 256.25 25.00
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 912 1409.50 70475.00 50.00
CONSP-CONSP-CONSULT, SLP, PHONE 168 212.25 5306.25 25.00
COUN-H2019HR-INDIVIDUAL/FAMILY THERAPY 2 4.00 140.00 35.00
ECE-ECE-EARLY CHILDHOOD EDUCATION 81 12438.4 112136.00 9.02
EIGF-EIGF_NM-EI GROUP SESSION BY NONMED PROF 109 8883.00 221965.96 24.99
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 159 2486.50 62667.38 25.20
EIIF-90847-FAMILY PSYCHOTHERAPY WITH PATIENT 1 5.00 306.35 61.27
EIIF-96154-HEALTH AND BEHAVIOR INTERVENTION 46 372.50 18200.00 48.86
EIIF-EIIF_NM-EI INDIVIDUAL SESSION BY NONMED PROF 202 972.25 40780.32 41.94
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 5296 37369.0 1861586.53 49.82
HERN-EIIF_NM-EI HEARING SERVICES AFTER SHINE NONMED 11 43.00 2150.00 50.00
HERN-T1027SC-EI HEARING SERVICES AFTER SHINE 19 68.50 3425.00 50.00
INTR-INTR-INTERPRETER 181 986.50 39836.50 40.38
OCCT-97530-OT SESSION BY LICENSED OT 1905 10718.8 713403.67 66.56
CMS/EIP Fiscal Report Statewide
Services beginning 10/01/2009 ending 12/31/2009 Date of Report:02/16/2010 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 64 262.50 14070.54 53.60
PHY-97110-PT SESSION BY LICENSED PT 2089 10614.9 705071.78 66.42
PHY-97110HM-PT SESSION BY PT ASST 83 303.78 16469.77 54.22
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 11 19.00 352.80 18.57
SHIN-T1027SC-INITIAL SHINE SERVICES, INDIVIDUAL 32 60.50 3025.00 50.00
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 4887 27700.2 1846421.76 66.66
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 29 81.50 4304.22 52.81
SPL-92508-GROUP SPL SESSION PER CHILD 98 193.53 2559.73 13.23
TRAN-TRAN-FAMILY TRANSPORTATION 374 851.00 3405.01 4.00
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 9332 1979076 1045363.54 0.53
VISN-EIIF_NM-EI VISION SERVICES, IND NONMED 20 108.50 5425.00 50.00
VISN-T1027SC-EI VISION SERVICES, INDIVIDUAL 8 36.00 1800.00 50.00
Subtotal (Total Children Is Unduplicated) 12079 2098859 6982484.76 3.33
----------------------------------------------------------------------------------------------------------------
Total 2196688.72 10707070.40 4.87
----------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 21883
----------------------------------------------------------------------------------------------------------------
Center 01
Flag Claims Units Chgs Paid
-------------------------------------------------
R 270 181.50 7041.50 0.00
U 0 0.00 0.00 0.00
B 3664 2688.50 101272.75 0.00
P 6000 157198.50 235405.85 235295.47
D 274 409.75 27298.25 0.00
S 2537 1913.50 70660.75 0.00
H 4 7.00 525.00 0.00
T 3604 99998.50 162500.02 162550.02
9530 13032.25 367668.04 3500.00
Other 1503 11579.25 118767.47 0.00
-------------------------------------------------
Total 27386 287008.75 1091139.63 401345.49
Center 02
Flag Claims Units Chgs Paid
-------------------------------------------------
R 17 195.00 7541.00 0.00
U 0 0.00 0.00 0.00
B 716 3291.50 123315.00 0.00
P 1 157199.00 235424.35 235295.47
D 0 409.75 27298.25 0.00
S 1 1914.75 70707.00 0.00
H 0 7.00 525.00 0.00
T 902 147079.25 224495.22 224545.22
1701 47863.25 448316.56 3500.00
Other 0 11579.25 118767.47 0.00
-------------------------------------------------
Total 3338 369538.75 1256389.85 463340.69
Center 03
Flag Claims Units Chgs Paid
-------------------------------------------------
R 51 241.00 9448.50 0.00
U 0 0.00 0.00 0.00
B 71 3348.00 125500.00 0.00
P 4809 193013.25 397004.40 396850.77
D 0 409.75 27298.25 0.00
S 0 1914.75 70707.00 0.00
H 0 7.00 525.00 0.00
T 4038 149857.50 311632.56 311682.56
6602 116891.00 675876.53 3500.00
Other 138 11717.25 120918.17 0.00
-------------------------------------------------
Total 15709 477399.50 1738910.41 712033.33
Center 04
Flag Claims Units Chgs Paid
-------------------------------------------------
R 322 578.50 22916.50 0.00
U 0 0.00 0.00 0.00
B 2034 5419.75 211054.00 0.00
P 4432 321404.50 665922.21 659479.37
D 1 473.75 27330.25 32.00
S 0 1914.75 70707.00 0.00
H 1721 18189.25 244706.87 243884.45
T 1 149858.75 311678.81 311682.56
6286 132972.75 1179769.37 3903.64
Other 0 11717.25 120918.17 0.00
-------------------------------------------------
Total 14797 642529.25 2855003.18 1218982.02
Center 05
Flag Claims Units Chgs Paid
-------------------------------------------------
R 149 674.25 26459.25 0.00
U 0 0.00 0.00 0.00
B 2040 6493.75 250976.15 0.00
P 1566 362179.27 734661.01 728218.17
D 0 473.75 27330.25 32.00
S 0 1914.75 70707.00 0.00
H 0 18189.25 244706.87 243884.45
T 0 149858.75 311678.81 311682.56
7538 198126.45 1419194.81 3903.64
Other 0 11717.25 120918.17 0.00
-------------------------------------------------
Total 11293 749627.47 3206632.32 1287720.82
Center 06
Flag Claims Units Chgs Paid
-------------------------------------------------
R 26 689.50 27023.50 0.00
U 0 0.00 0.00 0.00
B 192 6615.25 255471.65 434.75
P 8488 426066.27 947226.21 940815.49
D 0 473.75 27330.25 32.00
S 0 1914.75 70707.00 0.00
H 0 18189.25 244706.87 243884.45
T 0 149858.75 311678.81 311682.56
18449 287207.70 1999164.71 5434.58
Other 0 11717.25 120918.17 0.00
-------------------------------------------------
Total 27155 902732.47 4004227.17 1502283.83
Center 07
Flag Claims Units Chgs Paid
-------------------------------------------------
R 244 846.50 32832.50 0.00
U 0 0.00 0.00 0.00
B 4277 9459.25 370812.46 434.75
P 3781 541028.02 1296027.43 1289596.71
D 39 492.00 28005.50 32.00
S 6 1922.00 70975.25 0.00
H 0 18189.25 244706.87 243884.45
T 0 149858.75 311678.81 311682.56
10224 303264.45 2375087.42 5434.58
Other 0 11717.25 120918.17 0.00
-------------------------------------------------
Total 18571 1036777.47 4851044.41 1851065.05
Center 09
Flag Claims Units Chgs Paid
-------------------------------------------------
R 117 932.25 36220.75 0.00
U 0 0.00 0.00 0.00
B 3161 12181.00 498122.37 481.00
P 10133 695976.77 1826915.85 1905380.20
D 0 492.00 28005.50 32.00
S 0 1922.00 70975.25 0.00
H 0 18189.25 244706.87 243884.45
T 5176 231653.75 588373.04 588376.79
4323 319416.20 2817660.01 5847.07
Other 0 11717.25 120918.17 0.00
-------------------------------------------------
Total 22910 1292480.47 6231897.81 2744001.51
Center 10
Flag Claims Units Chgs Paid
-------------------------------------------------
R 684 1370.25 53438.50 0.00
U 0 0.00 0.00 0.00
B 6743 16688.50 678613.12 481.00
P 4580 807146.02 2176398.63 2254807.48
D 41 514.00 28914.50 931.75
S 128 1991.25 73537.50 0.00
H 0 18189.25 244706.87 243884.45
T 0 231653.75 588373.04 588376.79
10758 330416.70 3322162.01 5847.07
Other 0 11717.25 120918.17 0.00
-------------------------------------------------
Total 22934 1419686.97 7287062.34 3094328.54
Center 51
Flag Claims Units Chgs Paid
-------------------------------------------------
R 60 1416.00 55416.25 0.00
U 0 0.00 0.00 0.00
B 3379 19316.00 777192.43 481.00
P 2250 906174.52 2340961.00 2419369.85
D 4 517.50 29047.50 931.75
S 0 1991.25 73537.50 0.00
H 0 18189.25 244706.87 243884.45
T 1 231654.75 588410.04 588376.79
4524 336314.45 3599258.55 5847.07
Other 0 11717.25 120918.17 0.00
-------------------------------------------------
Total 10218 1527290.97 7829448.31 3258890.91
Center 52
Flag Claims Units Chgs Paid
-------------------------------------------------
R 234 1594.00 64443.01 0.00
U 0 0.00 0.00 0.00
B 953 19949.75 806565.40 481.00
P 2063 944281.42 2421800.12 2500208.97
D 0 517.50 29047.50 931.75
S 87 2057.75 75850.00 0.00
H 64 18309.75 253061.84 243884.45
T 0 231654.75 588410.04 588376.79
6974 425029.76 3944451.61 5847.07
Other 0 11717.25 120918.17 0.00
-------------------------------------------------
Total 10375 1655111.93 8304547.69 3339730.03
Center 53
Flag Claims Units Chgs Paid
-------------------------------------------------
R 381 2005.75 83973.14 0.00
U 0 0.00 0.00 0.00
B 628 20424.25 824908.90 481.00
P 1424 945615.63 2485172.96 2562144.87
D 4 522.50 29347.50 931.75
S 0 2057.75 75850.00 0.00
H 623 36132.75 279407.41 270230.02
T 751 250761.97 620807.88 620750.63
8024 495242.00 4233210.15 6047.07
Other 1 11719.25 121029.17 83.25
-------------------------------------------------
Total 11836 1764481.85 8753707.11 3460668.59
Center 54
Flag Claims Units Chgs Paid
-------------------------------------------------
R 69 2071.75 86877.64 0.00
U 0 0.00 0.00 0.00
B 2099 22085.25 895443.83 481.00
P 5143 1091957.53 2840551.83 2917485.86
D 114 598.00 32574.23 931.75
S 0 2057.75 75850.00 0.00
H 0 36132.75 279407.41 270230.02
T 0 250761.97 620807.88 620750.63
5638 547815.61 4487695.90 6047.07
Other 0 11719.25 121029.17 83.25
-------------------------------------------------
Total 13063 1965199.86 9440237.89 3816009.58
Center 55
Flag Claims Units Chgs Paid
-------------------------------------------------
R 20 2094.00 87702.39 0.00
U 0 0.00 0.00 0.00
B 272 22314.50 903694.83 481.00
P 3409 1131275.35 2945300.42 3022225.20
D 42 642.25 34411.23 931.75
S 2 2060.25 75942.50 0.00
H 1 36134.25 279657.41 270230.02
T 966 266403.57 649753.64 649696.39
5411 566284.80 4685820.05 6047.07
Other 0 11719.25 121029.17 83.25
-------------------------------------------------
Total 10123 2038928.22 9783311.64 3949694.68
Center 57
Flag Claims Units Chgs Paid
-------------------------------------------------
R 187 2278.00 94595.14 0.00
U 0 0.00 0.00 0.00
B 976 23321.50 945280.83 481.00
P 1 1131277.35 2945374.42 3022299.20
D 10 651.75 34894.23 931.75
S 197 5943.75 85303.40 9360.90
H 0 36134.25 279657.41 270230.02
T 5438 395701.21 1020864.58 1021482.03
4844 589314.16 5176417.44 201716.07
Other 90 12066.75 124682.95 3737.03
-------------------------------------------------
Total 11743 2196688.7210707070.40 4530238.00