CMS/EIP Fiscal Report Statewide
Services beginning 10/01/2009 ending 12/31/2009 Date of Report:02/16/2010 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 7440 4709.25 174214.50 36.99
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 5657 6519.00 0.00 0.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 6425 7169.50 262478.00 36.61
TCM-T1017TL-TARGETED CASE MANAGEMENT 9309 27652.0 1022219.50 36.97
TCON-TCON-TRANSITION CONFERENCE 1009 1090.00 0.00 0.00
Subtotal (Total Children Is Unduplicated) 16529 47139.8 1458912.00 30.95
----------------------------------------------------------------------------------------------------------------
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 21 22.00 233.64 10.62
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 47 48.00 423.84 8.83
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 55 56.00 585.30 10.45
AUDE-92568-ACOUSTIC REFLEX TESTING (MEMR) 2 2.00 16.88 8.44
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 57 58.00 1263.82 21.79
AUDE-92585-AUD EVOKED RESPONSE (DIAG) 1 1.00 54.38 54.38
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 28 28.29 777.59 27.49
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 87 97.50 4800.00 49.23
EXIT-EXIT-TRANSITION ASSESSMENT 529 831.50 41625.00 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 51 70.32 5273.36 74.99
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 20 31.50 2362.50 75.00
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 10 12.50 937.50 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 40 42.50 3187.50 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 54 80.00 4440.00 55.50
IPDEI-IPDEI_NM-INITIAL PSYCH & DEV EVAL BY NON-MED PR 87 148.70 8026.18 53.98
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 626 886.43 65622.31 74.03
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 225 392.69 29118.72 74.15
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 117 164.10 12114.89 73.83
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 737 1199.80 66561.75 55.48
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 442 659.59 49318.20 74.77
MED-99202-OUTPATIENT VISIT, NEW, 20 MINS 1 1.00 27.22 27.22
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 8 9.00 942.50 104.72
MED-99204-OUTPATIENT VISIT, NEW, 45 MINS 1 1.00 57.27 57.27
MED-99205-OUTPATIENT VISIT, NEW, 60 MINS 5 5.00 363.90 72.78
NUTR-97802-NUTRITIONAL EVAL, INITIAL 1 0.75 37.50 50.00
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 30 31.00 1318.09 42.52
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 85 85.37 4016.95 47.05
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 23 22.75 1079.96 47.47
PSTH-97001-EVAL BY LICENSED PT, INITIAL 57 56.25 2573.05 45.74
SCREEN-T1023-INTERDISCIPLINARY SCREENING 37 39.00 1950.00 50.00
SPCH-92506-SPEECH EVAL BY LICENSED SLP 240 247.31 11795.45 47.70
Subtotal (Total Children Is Unduplicated) 2484 5377.85 324181.46 60.28
----------------------------------------------------------------------------------------------------------------
EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 40 83.00 13608.51 163.96
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 791 965.75 47062.50 48.73
COIFP-COIFP-IFSP CONSULT, PRO, BY PHONE 66 41.00 1006.25 24.54
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 992 1605.00 77775.00 48.46
CONIP-CONIP-CONSULT, ITDS, PHONE 168 189.75 4725.00 24.90
CONOF-CONOF-CONSULT, OT, FACE TO FACE 226 252.25 12612.50 50.00
CONOP-CONOP-CONSULT, OT, PHONE 27 17.50 437.50 25.00
CONPF-CONPF-CONSULT, PT, FACE TO FACE 200 221.00 11012.50 49.83
CONPP-CONPP-CONSULT, PT, PHONE 17 10.25 256.25 25.00
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 901 1372.50 68625.00 50.00
CONSP-CONSP-CONSULT, SLP, PHONE 162 203.75 5093.75 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 65 270.00 7249.88 26.85
EIIF-90847-FAMILY PSYCHOTHERAPY WITH PATIENT 1 5.00 306.35 61.27
EIIF-96154-HEALTH AND BEHAVIOR INTERVENTION 45 357.50 17450.00 48.81
EIIF-EIIF_NM-EI INDIVIDUAL SESSION BY NONMED PROF 79 376.25 16417.82 43.64
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 2462 17505.1 869258.75 49.66
HERN-T1027SC-EI HEARING SERVICES AFTER SHINE 8 29.00 1450.00 50.00
INTR-INTR-INTERPRETER 181 986.50 39836.50 40.38
OCCT-97530-OT SESSION BY LICENSED OT 891 4786.06 309988.20 64.77
OCCT-97530HM-OT SESSION BY OT ASST 28 93.95 4915.38 52.32
PHY-97110-PT SESSION BY LICENSED PT 839 3979.35 255483.62 64.20
PHY-97110HM-PT SESSION BY PT ASST 14 39.46 2104.99 53.34
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
CMS/EIP Fiscal Report Statewide
Services beginning 10/01/2009 ending 12/31/2009 Date of Report:02/16/2010 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-V5264-EARMOLD 6 11.00 203.04 18.46
SHIN-T1027SC-INITIAL SHINE SERVICES, INDIVIDUAL 14 21.50 1075.00 50.00
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 2845 16391.9 1079007.11 65.83
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 20 54.50 2840.17 52.11
SPL-92508-GROUP SPL SESSION PER CHILD 21 46.25 608.48 13.16
TRAN-TRAN-FAMILY TRANSPORTATION 374 851.00 3405.01 4.00
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 9298 1968224 1039654.74 0.53
VISN-EIIF_NM-EI VISION SERVICES, IND NONMED 1 1.00 50.00 50.00
VISN-T1027SC-EI VISION SERVICES, INDIVIDUAL 7 15.00 750.00 50.00
Subtotal (Total Children Is Unduplicated) 10969 2019196 3900062.57 1.93
----------------------------------------------------------------------------------------------------------------
Total 2071713.54 5683156.03 2.74
----------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 19084
----------------------------------------------------------------------------------------------------------------
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 5845 157002.25 225611.22 225661.22
D 12 20.00 1322.00 0.00
S 247 215.50 7973.50 0.00
H 0 0.00 0.00 0.00
T 3603 99995.50 162350.02 162350.02
7645 9416.25 184303.87 0.00
Other 427 9972.50 19016.28 0.00
-------------------------------------------------
Total 17779 276622.00 600576.89 388011.24
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 157002.25 225611.22 225661.22
D 0 20.00 1322.00 0.00
S 0 215.50 7973.50 0.00
H 0 0.00 0.00 0.00
T 902 147076.25 224345.22 224345.22
1583 44060.00 253899.14 0.00
Other 0 9972.50 19016.28 0.00
-------------------------------------------------
Total 2485 358346.50 732167.36 450006.44
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 2302 190979.50 314353.27 314403.27
D 0 20.00 1322.00 0.00
S 0 215.50 7973.50 0.00
H 0 0.00 0.00 0.00
T 4038 149854.50 311482.56 311482.56
6455 112958.00 476312.68 0.00
Other 4 9976.50 19077.52 0.00
-------------------------------------------------
Total 12799 464004.00 1130521.53 625885.83
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 2243 317073.75 497149.90 490715.14
D 1 84.00 1354.00 32.00
S 0 215.50 7973.50 0.00
H 243 13742.00 9240.22 8901.32
T 0 149854.50 311482.56 311482.56
5083 116881.25 605347.18 0.00
Other 0 9976.50 19077.52 0.00
-------------------------------------------------
Total 7570 607827.50 1451624.88 811131.02
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 1509 357725.52 559798.70 553363.94
D 0 84.00 1354.00 32.00
S 0 215.50 7973.50 0.00
H 0 13742.00 9240.22 8901.32
T 0 149854.50 311482.56 311482.56
6115 180304.32 780627.36 0.00
Other 0 9976.50 19077.52 0.00
-------------------------------------------------
Total 7624 711902.34 1689553.86 873779.82
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 4595 419110.52 679276.90 672874.26
D 0 84.00 1354.00 32.00
S 0 215.50 7973.50 0.00
H 0 13742.00 9240.22 8901.32
T 0 149854.50 311482.56 311482.56
13471 265094.32 1102350.54 1305.94
Other 0 9976.50 19077.52 0.00
-------------------------------------------------
Total 18066 858077.34 2130755.24 994596.08
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 3375 533702.52 1010787.84 1004365.20
D 39 102.25 2029.25 32.00
S 1 217.50 8047.50 0.00
H 0 13742.00 9240.22 8901.32
T 0 149854.50 311482.56 311482.56
8856 273786.07 1280639.19 1305.94
Other 0 9976.50 19077.52 0.00
-------------------------------------------------
Total 12271 981381.34 2641304.08 1326087.02
Center 09
Flag Claims Units Chgs Paid
-------------------------------------------------
R 0 0.00 0.00 0.00
U 0 0.00 0.00 0.00
B 1 1.75 64.75 0.00
P 9359 687927.27 1506290.23 1500102.99
D 0 102.25 2029.25 32.00
S 0 217.50 8047.50 0.00
H 0 13742.00 9240.22 8901.32
T 5176 231649.50 588176.79 588176.79
819 283392.82 1314315.40 1604.32
Other 0 9976.50 19077.52 0.00
-------------------------------------------------
Total 15355 1227009.59 3447241.66 2098817.42
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 1.75 64.75 0.00
P 3876 798318.77 1810105.26 1803918.02
D 41 124.25 2938.25 931.75
S 0 217.50 8047.50 0.00
H 0 13742.00 9240.22 8901.32
T 0 231649.50 588176.79 588176.79
8194 289501.57 1510416.90 1604.32
Other 0 9976.50 19077.52 0.00
-------------------------------------------------
Total 12111 1343531.84 3948067.19 2403532.20
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 1.75 64.75 0.00
P 2228 897285.27 1970731.74 1964544.50
D 4 127.75 3071.25 931.75
S 0 217.50 8047.50 0.00
H 0 13742.00 9240.22 8901.32
T 0 231649.50 588176.79 588176.79
3178 292196.07 1595992.34 1604.32
Other 0 9976.50 19077.52 0.00
-------------------------------------------------
Total 5410 1445196.34 4194402.11 2564158.68
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 1.75 64.75 0.00
P 747 934615.25 2021678.64 2015491.40
D 0 127.75 3071.25 931.75
S 5 221.75 8130.75 0.00
H 0 13742.00 9240.22 8901.32
T 0 231649.50 588176.79 588176.79
5573 376404.01 1765836.80 1604.32
Other 0 9976.50 19077.52 0.00
-------------------------------------------------
Total 6325 1566738.51 4415276.72 2615105.58
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 1.75 64.75 0.00
P 0 934615.25 2021678.64 2015491.40
D 0 127.75 3071.25 931.75
S 0 221.75 8130.75 0.00
H 623 31565.00 35585.79 35246.89
T 751 250756.72 620574.63 620550.63
5081 444067.39 1917330.58 1604.32
Other 0 9976.50 19077.52 0.00
-------------------------------------------------
Total 6455 1671332.11 4625513.91 2673824.99
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 1.75 64.75 0.00
P 2791 1079241.65 2306573.90 2300386.66
D 74 174.75 4834.50 931.75
S 0 221.75 8130.75 0.00
H 0 31565.00 35585.79 35246.89
T 0 250756.72 620574.63 620550.63
4557 493292.09 2055333.37 1604.32
Other 0 9976.50 19077.52 0.00
-------------------------------------------------
Total 7422 1865230.21 5050175.21 2958720.25
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 1.75 64.75 0.00
P 2537 1117756.72 2379781.36 2373594.12
D 42 219.00 6671.50 931.75
S 0 221.75 8130.75 0.00
H 0 31565.00 35585.79 35246.89
T 966 266398.32 649520.39 649496.39
2678 509648.11 2118339.66 1604.32
Other 0 9976.50 19077.52 0.00
-------------------------------------------------
Total 6223 1935787.15 5217171.72 3060873.47
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 1.75 64.75 0.00
P 0 1117756.72 2379781.36 2373594.12
D 10 228.50 7154.50 931.75
S 197 4105.25 17491.65 9360.90
H 0 31565.00 35585.79 35246.89
T 5428 395664.96 1018975.55 1019626.25
2464 512377.86 2204932.41 1854.32
Other 4 10013.50 19170.02 92.50
-------------------------------------------------
Total 8103 2071713.54 5683156.03 3440706.73