CMS/EIP Fiscal Report Statewide
Services beginning 01/01/2010 ending 03/31/2010 Date of Report:05/17/2010 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 7522 5124.50 189532.50 36.99
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 6160 6961.00 0.00 0.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 6641 7426.75 274633.00 36.98
TCM-T1017TL-TARGETED CASE MANAGEMENT 9178 29391.3 1086756.75 36.98
TCON-TCON-TRANSITION CONFERENCE 1184 1192.00 0.00 0.00
Subtotal (Total Children Is Unduplicated) 16689 50095.5 1550922.25 30.96
----------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
ASTE-ASTE-ASSISTIVE TECHNOLOGY EVAL 9 14.00 655.50 46.82
AUDE-92552-PURE TONE AUDIOMETRY -AIR ONLY 20 20.00 212.40 10.62
AUDE-92553-PURE TONE AUDIOMETRY AIR & BONE 4 4.00 65.20 16.30
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 44 45.00 395.30 8.78
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 48 51.00 532.72 10.45
AUDE-92568-ACOUSTIC REFLEX TESTING (MEMR) 3 3.00 25.32 8.44
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 48 50.00 1074.63 21.49
AUDE-92585-AUD EVOKED RESPONSE (DIAG) 3 3.00 114.50 38.17
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 23 23.00 647.00 28.13
AUDE-92588-OTOACOUSTIC EMISSIONS (COMP) 3 3.00 95.14 31.71
AUDE-V5010-ASSESSMENT FOR HEARING AID 2 3.00 138.60 46.20
AUDE-V5090-DISPENSING FEE PER HEARING AID 3 5.00 588.80 117.76
BEHV-H0031HO-COMP BEHAVIORAL HEALTH ASSESSMENT 12 14.00 1650.00 117.86
EVAL-EVAL-DEVELOPMENTAL EVALUATION 76 75.25 3773.50 50.15
EXIT-EXIT-TRANSITION ASSESSMENT 637 1042.25 52137.50 50.02
IPDEF-IPDEF_NM-F/U PSYCH & DEV EVAL BY NON-MED PROF 6 10.00 549.50 54.95
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 55 89.50 6712.50 75.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 12 19.50 1462.50 75.00
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 4 4.00 300.00 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 55 70.00 5250.00 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 47 80.50 4467.75 55.50
IPDEI-IPDEI_NM-INITIAL PSYCH & DEV EVAL BY NON-MED PR 117 204.26 11037.71 54.04
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 652 924.39 68984.49 74.63
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 167 275.36 20652.05 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 122 168.63 12421.05 73.66
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 758 1316.58 69058.85 52.45
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 435 649.42 48444.05 74.60
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 20 20.00 1966.00 98.30
MED-99204-OUTPATIENT VISIT, NEW, 45 MINS 1 1.00 57.27 57.27
MED-99205-OUTPATIENT VISIT, NEW, 60 MINS 2 2.00 145.56 72.78
NUTR-97802-NUTRITIONAL EVAL, INITIAL 6 6.75 337.50 50.00
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 36 36.00 1746.00 48.50
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 80 79.49 3729.04 46.91
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 28 26.53 1262.09 47.57
PSTH-97001-EVAL BY LICENSED PT, INITIAL 56 80.25 3845.63 47.92
SCREEN-T1023-INTERDISCIPLINARY SCREENING 118 133.00 6650.00 50.00
SENS-V5014TS-HEARING AID REPAIR IN-OFFICE 2 3.00 45.00 15.00
SPCH-92506-SPEECH EVAL BY LICENSED SLP 295 298.95 14433.60 48.28
VISF-VISF-VISION EVALUATION FUNCTIONAL 1 1.00 225.00 225.00
Subtotal (Total Children Is Unduplicated) 2732 5855.61 345889.25 59.07
----------------------------------------------------------------------------------------------------------------
EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 54 166.00 22788.54 137.28
AUD-92630-AUD REHAB PRELING HEARING LOSS 1 2.00 137.72 68.86
AUD-HA_FUP-AUDIOLOGY SERVICES 1 2.00 67.39 33.70
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 772 958.00 47873.75 49.97
COIFP-COIFP-IFSP CONSULT, PRO, BY PHONE 35 30.25 756.25 25.00
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 933 1145.75 57287.50 50.00
CONIP-CONIP-CONSULT, ITDS, PHONE 158 140.50 3512.50 25.00
CONOF-CONOF-CONSULT, OT, FACE TO FACE 224 248.50 11137.50 44.82
CONOP-CONOP-CONSULT, OT, PHONE 39 21.75 543.75 25.00
CONPF-CONPF-CONSULT, PT, FACE TO FACE 209 225.75 11330.00 50.19
CONPP-CONPP-CONSULT, PT, PHONE 33 19.50 487.50 25.00
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 795 1109.75 55513.75 50.02
CONSP-CONSP-CONSULT, SLP, PHONE 123 123.25 3081.25 25.00
ECE-ECE-EARLY CHILDHOOD EDUCATION 2 191.20 2390.00 12.50
EIGF-EIGF_NM-EI GROUP SESSION BY NONMED PROF 11 31.25 712.63 22.80
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 55 281.00 7577.74 26.97
EIIF-96154-HEALTH AND BEHAVIOR INTERVENTION 73 670.25 33512.50 50.00
EIIF-EIIF_NM-EI INDIVIDUAL SESSION BY NONMED PROF 78 320.25 14486.12 45.23
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 2378 16890.7 840085.54 49.74
HERN-T1027SC-EI HEARING SERVICES AFTER SHINE 5 12.00 600.00 50.00
INTR-INTR-INTERPRETER 198 1009.50 45199.97 44.77
OCCT-97530-OT SESSION BY LICENSED OT 870 4579.17 296346.66 64.72
OCCT-97530HM-OT SESSION BY OT ASST 54 227.27 11765.08 51.77
PHY-97110-PT SESSION BY LICENSED PT 877 4430.59 284405.62 64.19
PHY-97110HM-PT SESSION BY PT ASST 21 104.00 5109.09 49.13
RSPT-RSPT-RESPITE 1 89.50 716.00 8.00
SENS-HA_EIP-ONE UNIT UP TO $500 PER AID 1 2.00 1000.00 500.00
SENS-HA_INS-SENSORY AID INSURANCE PER EAR 3 3.00 390.00 130.00
SENS-V5014-HEARING AID REPAIR BY MANUFACTURER 2 2.00 228.00 114.00
CMS/EIP Fiscal Report Statewide
Services beginning 01/01/2010 ending 03/31/2010 Date of Report:05/17/2010 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-V5050-MED HEARING AID - ANALOG/DIGITAL 1 2.00 474.24 237.12
SENS-V5264-EARMOLD 8 14.00 259.20 18.51
SHIN-T1027SC-INITIAL SHINE SERVICES, INDIVIDUAL 7 35.00 1750.00 50.00
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 2825 16543.7 1089286.63 65.84
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 39 168.25 9139.34 54.32
SPL-92508-GROUP SPL SESSION PER CHILD 6 44.00 530.60 12.06
TRAN-TRAN-FAMILY TRANSPORTATION 352 1035.00 3072.29 2.97
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 9605 2112765 1121864.99 0.53
VISN-EIIF_NM-EI VISION SERVICES, IND NONMED 4 19.50 975.00 50.00
VISN-T1027SC-EI VISION SERVICES, INDIVIDUAL 5 37.00 365.00 9.86
Subtotal (Total Children Is Unduplicated) 11212 2163700 3986759.64 1.84
----------------------------------------------------------------------------------------------------------------
Total 2219651.21 5883571.14 2.65
----------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 19235
----------------------------------------------------------------------------------------------------------------
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 5418 158807.61 236795.79 236904.43
D 0 0.00 0.00 0.00
S 95 97.50 3607.50 0.00
H 0 0.00 0.00 0.00
T 3478 90861.50 164539.24 165246.07
7118 6910.25 166937.43 0.00
Other 1139 30909.75 39558.95 220.00
-------------------------------------------------
Total 17248 287586.61 611438.91 402370.50
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 158807.61 236795.79 236904.43
D 0 0.00 0.00 0.00
S 0 97.50 3607.50 0.00
H 0 0.00 0.00 0.00
T 1032 136640.75 228813.54 229520.37
2018 48802.75 257027.44 0.00
Other 0 30909.75 39558.95 220.00
-------------------------------------------------
Total 3050 375258.36 765803.22 466644.80
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 5194 234508.36 433557.51 433679.90
D 0 0.00 0.00 0.00
S 0 97.50 3607.50 0.00
H 0 0.00 0.00 0.00
T 3547 139158.50 308800.77 309507.60
4784 89255.50 401352.83 0.00
Other 4 30913.75 39620.19 220.00
-------------------------------------------------
Total 13529 493933.61 1186938.80 743407.50
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 2025 353243.11 583263.58 583375.97
D 13 16.75 619.75 203.50
S 0 97.50 3607.50 0.00
H 130 6009.50 9499.42 9499.42
T 0 139158.50 308800.77 309507.60
4857 92948.50 522932.08 0.00
Other 0 30913.75 39620.19 220.00
-------------------------------------------------
Total 7025 622387.61 1468343.29 902806.49
Center 05
Flag Claims Units Chgs Paid
-------------------------------------------------
R 0 0.00 0.00 0.00
U 0 0.00 0.00 0.00
B 12 5.25 194.25 0.00
P 1009 375837.19 624580.69 624693.08
D 0 16.75 619.75 203.50
S 0 97.50 3607.50 0.00
H 0 6009.50 9499.42 9499.42
T 0 139158.50 308800.77 309507.60
6347 167023.20 699601.94 0.00
Other 0 30913.75 39620.19 220.00
-------------------------------------------------
Total 7368 719061.64 1686524.51 944123.60
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 5.25 194.25 0.00
P 5325 441347.94 760670.10 760782.49
D 0 16.75 619.75 203.50
S 0 97.50 3607.50 0.00
H 1 6010.25 9550.33 9499.42
T 0 139158.50 308800.77 309507.60
13735 256278.45 1023007.26 3066.65
Other 0 30913.75 39620.19 220.00
-------------------------------------------------
Total 19061 873828.39 2146070.15 1083279.66
Center 07
Flag Claims Units Chgs Paid
-------------------------------------------------
R 0 0.00 0.00 0.00
U 0 0.00 0.00 0.00
B 3 8.00 296.00 0.00
P 3332 570585.69 1081816.15 1081928.54
D 14 23.50 869.50 203.50
S 26 107.00 3959.00 0.00
H 0 6010.25 9550.33 9499.42
T 0 139158.50 308800.77 309507.60
9457 266369.45 1221378.07 3066.65
Other 0 30913.75 39620.19 220.00
-------------------------------------------------
Total 12832 1013176.14 2666290.01 1404425.71
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 8.00 296.00 0.00
P 9999 733629.44 1601598.04 1602214.01
D 0 23.50 869.50 203.50
S 0 107.00 3959.00 0.00
H 0 6010.25 9550.33 9499.42
T 5775 239916.75 640320.31 641027.14
440 269867.70 1245315.79 4229.86
Other 0 30913.75 39620.19 220.00
-------------------------------------------------
Total 16214 1280476.39 3541529.16 2257393.93
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 8.00 296.00 0.00
P 4226 861781.19 1926042.92 1926658.89
D 65 60.75 2494.25 1828.25
S 0 107.00 3959.00 0.00
H 0 6010.25 9550.33 9499.42
T 0 239916.75 640320.31 641027.14
8032 275820.95 1434094.29 4229.86
Other 0 30913.75 39620.19 220.00
-------------------------------------------------
Total 12323 1414618.64 4056377.29 2583463.56
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 8.00 296.00 0.00
P 2554 973118.69 2123297.14 2123913.11
D 14 73.00 2958.00 1828.25
S 0 107.00 3959.00 0.00
H 0 6010.25 9550.33 9499.42
T 0 239916.75 640320.31 641027.14
3534 278329.95 1523037.96 4229.86
Other 0 30913.75 39620.19 220.00
-------------------------------------------------
Total 6102 1528477.39 4343038.93 2780717.78
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 8.00 296.00 0.00
P 702 1007680.31 2170173.39 2170789.36
D 0 73.00 2958.00 1828.25
S 0 107.00 3959.00 0.00
H 0 6010.25 9550.33 9499.42
T 0 239916.75 640320.31 641027.14
5907 385262.97 1703463.84 4229.86
Other 0 30913.75 39620.19 220.00
-------------------------------------------------
Total 6609 1669972.03 4570341.06 2827594.03
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 8.00 296.00 0.00
P 0 1007680.31 2170173.39 2170789.36
D 0 73.00 2958.00 1828.25
S 0 107.00 3959.00 0.00
H 649 25104.65 37356.32 37286.66
T 649 260171.75 669054.04 669760.87
3339 442529.14 1814133.99 4229.86
Other 0 30913.75 39620.19 220.00
-------------------------------------------------
Total 4637 1766587.60 4737550.93 2884115.00
Center 54
Flag Claims Units Chgs Paid
-------------------------------------------------
R 29 31.00 1147.00 0.00
U 0 0.00 0.00 0.00
B 0 8.00 296.00 0.00
P 3046 1170207.04 2461530.21 2462146.18
D 1 73.50 2976.50 1828.25
S 0 107.00 3959.00 0.00
H 0 25104.65 37356.32 37286.66
T 0 260171.75 669054.04 669760.87
4759 495918.14 1956423.24 4229.86
Other 0 30913.75 39620.19 220.00
-------------------------------------------------
Total 7835 1982534.83 5172362.50 3175471.82
Center 55
Flag Claims Units Chgs Paid
-------------------------------------------------
R 0 31.00 1147.00 0.00
U 0 0.00 0.00 0.00
B 0 8.00 296.00 0.00
P 1542 1196756.22 2504685.56 2505301.53
D 55 128.50 6313.50 1828.25
S 0 107.00 3959.00 0.00
H 0 25104.65 37356.32 37286.66
T 3899 320655.47 785620.74 786327.57
2115 497668.64 2001006.67 4229.86
Other 0 30913.75 39620.19 220.00
-------------------------------------------------
Total 7611 2071373.23 5380004.98 3335193.87
Center 57
Flag Claims Units Chgs Paid
-------------------------------------------------
R 0 31.00 1147.00 0.00
U 0 0.00 0.00 0.00
B 0 8.00 296.00 0.00
P 0 1196756.22 2504685.56 2505301.53
D 11 144.75 7187.50 1828.25
S 225 6305.00 16173.44 12214.44
H 0 25104.65 37356.32 37286.66
T 4650 458004.20 1122697.96 1121959.22
4384 502381.64 2154308.67 4529.86
Other 3 30915.75 39718.69 318.50
-------------------------------------------------
Total 9273 2219651.21 5883571.14 3683438.46