CMS/EIP Fiscal Report Statewide
Services beginning 04/01/2010 ending 06/30/2010 Date of Report:08/18/2010 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 8181 5325.75 196973.75 36.99
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 6389 7265.00 0.00 0.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 7180 8026.00 296666.00 36.96
TCM-T1017TL-TARGETED CASE MANAGEMENT 9475 30083.8 1111850.00 36.96
TCON-TCON-TRANSITION CONFERENCE 1284 1411.00 0.00 0.00
Subtotal (Total Children Is Unduplicated) 17958 52111.5 1605489.75 30.81
----------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
AACIS-92597-AAC INTIAL EVAL BY LICENSED SLP 1 1.00 97.50 97.50
ASTE-ASTE-ASSISTIVE TECHNOLOGY EVAL 8 9.00 436.50 48.50
AUD-92626-EVAL OF AUD REHAB STATUS 1 2.00 54.10 27.05
AUDE-92552-PURE TONE AUDIOMETRY -AIR ONLY 15 15.00 159.30 10.62
AUDE-92553-PURE TONE AUDIOMETRY AIR & BONE 3 3.00 48.90 16.30
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 54 57.00 493.23 8.65
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 61 63.00 670.52 10.64
AUDE-92568-ACOUSTIC REFLEX TESTING (MEMR) 3 3.00 25.32 8.44
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 62 64.00 1339.58 20.93
AUDE-92585-AUD EVOKED RESPONSE (DIAG) 4 5.00 271.90 54.38
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 24 24.00 677.63 28.23
AUDE-92588-OTOACOUSTIC EMISSIONS (COMP) 8 10.00 313.39 31.34
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 4 6.00 681.20 113.53
BEHV-H0031HO-COMP BEHAVIORAL HEALTH ASSESSMENT 16 20.00 2375.00 118.75
EVAL-EVAL-DEVELOPMENTAL EVALUATION 103 120.50 7490.75 62.16
EXIT-EXIT-TRANSITION ASSESSMENT 770 1317.50 66139.91 50.20
IPDEF-IPDEF_NM-F/U PSYCH & DEV EVAL BY NON-MED PROF 7 10.00 538.50 53.85
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 41 64.86 4864.50 75.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 14 15.82 1185.64 74.95
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 14 19.50 1462.50 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 59 64.32 4823.14 74.99
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 53 82.00 4551.00 55.50
IPDEI-IPDEI_NM-INITIAL PSYCH & DEV EVAL BY NON-MED PR 105 187.50 10282.25 54.84
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 679 957.77 71050.57 74.18
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 147 231.27 17344.35 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 150 207.67 15070.50 72.57
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 801 1315.00 72972.00 55.49
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 581 914.92 68909.59 75.32
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 18 21.00 2295.50 109.31
MED-99204-OUTPATIENT VISIT, NEW, 45 MINS 4 4.00 446.81 111.70
MED-99205-OUTPATIENT VISIT, NEW, 60 MINS 4 4.00 291.12 72.78
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 1 1.00 105.00 105.00
NUTR-97802-NUTRITIONAL EVAL, INITIAL 4 3.75 187.50 50.00
NUTR-NUTR-UNSPECIFIED NUTRITIONAL EVAL 2 3.00 150.00 50.00
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 39 39.00 1848.53 47.40
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 111 111.00 5256.07 47.35
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 19 20.00 920.22 46.01
PSTH-97001-EVAL BY LICENSED PT, INITIAL 80 81.72 3816.98 46.71
SCREEN-T1023-INTERDISCIPLINARY SCREENING 118 132.00 6575.00 49.81
SENS-V5014TS-HEARING AID REPAIR IN-OFFICE 1 1.00 15.00 15.00
SPCH-92506-SPEECH EVAL BY LICENSED SLP 300 300.80 14507.37 48.23
VISF-VISF-VISION EVALUATION FUNCTIONAL 3 7.50 675.00 90.00
Subtotal (Total Children Is Unduplicated) 3074 6523.40 391534.31 60.02
----------------------------------------------------------------------------------------------------------------
EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 52 93.00 28144.87 302.63
AUD-92630-AUD REHAB PRELING HEARING LOSS 2 5.00 138.71 27.74
AUD-92633-AUD REHAB POSTLING HEARING LOSS 1 1.00 68.86 68.86
AUD-HA_FUP-AUDIOLOGY SERVICES 3 3.00 126.92 42.31
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 929 1160.00 57289.94 49.39
COIFP-COIFP-IFSP CONSULT, PRO, BY PHONE 48 39.00 975.00 25.00
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 711 793.75 37212.50 46.88
CONIP-CONIP-CONSULT, ITDS, PHONE 116 86.00 2150.00 25.00
CONOF-CONOF-CONSULT, OT, FACE TO FACE 230 355.00 12765.00 35.96
CONOP-CONOP-CONSULT, OT, PHONE 33 20.25 506.25 25.00
CONPF-CONPF-CONSULT, PT, FACE TO FACE 195 238.00 11920.00 50.08
CONPP-CONPP-CONSULT, PT, PHONE 36 20.25 506.25 25.00
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 712 889.75 42200.00 47.43
CONSP-CONSP-CONSULT, SLP, PHONE 84 170.25 4256.25 25.00
COUN-H2019HR-INDIVIDUAL/FAMILY THERAPY 1 1.00 73.42 73.42
ECE-ECE-EARLY CHILDHOOD EDUCATION 2 216.40 2705.00 12.50
EIGF-EIGF_NM-EI GROUP SESSION BY NONMED PROF 17 46.75 833.37 17.83
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 60 320.50 8957.50 27.95
EIIF-96154-HEALTH AND BEHAVIOR INTERVENTION 95 879.00 43937.50 49.99
EIIF-EIIF_NM-EI INDIVIDUAL SESSION BY NONMED PROF 75 348.75 13845.48 39.70
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 2567 18654.8 915639.10 49.08
HERN-T1027SC-EI HEARING SERVICES AFTER SHINE 9 19.00 950.00 50.00
INTR-INTR-INTERPRETER 241 1258.25 55075.28 43.77
OCCT-97530-OT SESSION BY LICENSED OT 883 4956.44 319259.17 64.41
CMS/EIP Fiscal Report Statewide
Services beginning 04/01/2010 ending 06/30/2010 Date of Report:08/18/2010 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
OCCT-97530HM-OT SESSION BY OT ASST 66 349.96 18464.11 52.76
PHY-97110-PT SESSION BY LICENSED PT 842 4297.72 270373.43 62.91
PHY-97110HM-PT SESSION BY PT ASST 26 137.43 6845.01 49.81
RSPT-RSPT-RESPITE 2 91.00 633.10 6.96
SENS-HA_EIP-ONE UNIT UP TO $500 PER AID 2 3.00 1500.00 500.00
SENS-HA_INS-SENSORY AID INSURANCE PER EAR 1 1.00 130.00 130.00
SENS-V5014-HEARING AID REPAIR BY MANUFACTURER 1 2.00 30.00 15.00
SENS-V5050-MED HEARING AID - ANALOG/DIGITAL 2 3.00 711.36 237.12
SENS-V5264-EARMOLD 7 10.00 185.76 18.58
SHIN-T1027SC-INITIAL SHINE SERVICES, INDIVIDUAL 21 87.50 4375.00 50.00
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 3001 18899.6 1239846.35 65.60
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 29 156.00 8473.92 54.32
SPL-92508-GROUP SPL SESSION PER CHILD 16 220.50 2910.60 13.20
TRAN-TRAN-FAMILY TRANSPORTATION 396 1353.00 3655.39 2.70
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 10463 2362966 1245659.50 0.53
VISN-EIIF_NM-EI VISION SERVICES, IND NONMED 5 28.00 1400.00 50.00
VISN-T1027SC-EI VISION SERVICES, INDIVIDUAL 9 18.00 900.00 50.00
Subtotal (Total Children Is Unduplicated) 12071 2419199 4365629.90 1.80
----------------------------------------------------------------------------------------------------------------
Total 2477833.70 6362653.96 2.57
----------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 20561
----------------------------------------------------------------------------------------------------------------
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 3378 84900.00 115018.59 114824.96
D 1 0.50 12.50 0.00
S 6 6.25 322.50 0.00
H 4440 101532.25 139863.95 139863.95
T 4976 103643.25 198947.12 198947.12
7746 6865.50 171964.57 0.00
Other 603 15656.75 29880.80 132.07
-------------------------------------------------
Total 21150 312604.50 656010.03 453768.10
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 0.00 0.00 0.00
D 0 0.00 0.00 0.00
S 0 0.00 0.00 0.00
H 0 0.00 0.00 0.00
T 1195 51133.25 68410.12 68410.10
2205 38039.50 89664.98 0.00
Other 0 0.00 0.00 0.00
-------------------------------------------------
Total 3400 89172.75 158075.10 68410.10
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 5721 86044.00 206673.77 206673.77
D 0 0.00 0.00 0.00
S 0 0.00 0.00 0.00
H 0 0.00 0.00 0.00
T 4453 2907.50 94088.19 94088.19
4890 43269.50 144636.53 0.00
Other 11 11.00 163.90 0.00
-------------------------------------------------
Total 15075 132232.00 445562.39 300761.96
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 3142 160817.50 228303.87 228089.67
D 87 81.00 2997.00 2997.00
S 0 0.00 0.00 0.00
H 30 1314.50 2798.74 2798.74
T 0 0.00 0.00 0.00
4777 3894.75 128595.67 0.00
Other 0 0.00 0.00 0.00
-------------------------------------------------
Total 8036 166107.75 362695.28 233885.41
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 2247 68787.33 94026.76 62712.84
D 0 0.00 0.00 0.00
S 0 0.00 0.00 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
5054 50645.48 139159.85 0.00
Other 0 0.00 0.00 0.00
-------------------------------------------------
Total 7301 119432.81 233186.61 62712.84
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 244 2466.50 6946.36 7080.98
D 0 0.00 0.00 0.00
S 0 0.00 0.00 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
20136 153874.50 493394.17 212.75
Other 0 0.00 0.00 0.00
-------------------------------------------------
Total 20380 156341.00 500340.53 7293.73
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 3546 136952.42 340813.50 340813.50
D 0 0.00 0.00 0.00
S 15 6.00 222.00 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
9438 10916.00 196189.18 0.00
Other 0 0.00 0.00 0.00
-------------------------------------------------
Total 12999 147874.42 537224.68 340813.50
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 10742 192161.50 577125.67 577220.51
D 0 0.00 0.00 0.00
S 0 0.00 0.00 0.00
H 0 0.00 0.00 0.00
T 5869 111019.50 330073.77 330073.77
352 4690.25 25830.72 2071.63
Other 0 0.00 0.00 0.00
-------------------------------------------------
Total 16963 307871.25 933030.16 909365.91
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 4609 139458.75 348186.04 348186.04
D 70 40.00 1669.00 1659.75
S 0 0.00 0.00 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
7786 5895.75 184402.00 0.00
Other 5 1.75 64.75 0.00
-------------------------------------------------
Total 12470 145396.25 534321.79 349845.79
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 2866 121695.50 215510.34 215510.34
D 22 17.75 660.25 0.00
S 0 0.00 0.00 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
3813 3121.50 91019.86 0.00
Other 1 1.00 75.00 75.00
-------------------------------------------------
Total 6702 124835.75 307265.45 215585.34
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 718 37073.24 48162.57 48162.57
D 1 2.00 100.00 0.00
S 1 1.00 67.88 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
5789 106073.50 185810.79 0.00
Other 0 0.00 0.00 0.00
-------------------------------------------------
Total 6509 143149.74 234141.24 48162.57
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 1096 32610.50 49259.02 49259.02
D 4 7.00 335.00 185.00
S 0 0.00 0.00 0.00
H 694 22441.75 31400.99 31400.99
T 0 0.00 0.00 0.00
5122 71824.25 171959.16 13.20
Other 0 0.00 0.00 0.00
-------------------------------------------------
Total 6916 126883.50 252954.17 80858.21
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 3180 180388.03 303997.17 304016.67
D 44 31.75 1174.75 0.00
S 0 0.00 0.00 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
4896 49024.50 142126.02 0.00
Other 0 0.00 0.00 0.00
-------------------------------------------------
Total 8120 229444.28 447297.94 304016.67
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 3684 58888.01 104099.83 104099.83
D 35 34.00 2023.50 0.00
S 0 0.00 0.00 0.00
H 1 1.00 75.00 0.00
T 2284 32279.37 69305.73 69305.73
1973 1671.29 44622.63 0.00
Other 0 0.00 0.00 0.00
-------------------------------------------------
Total 7977 92873.67 220126.69 173405.56
Center 57
Flag Claims Units Chgs Paid
-------------------------------------------------
R 0 0.00 0.00 0.00
U 0 0.00 0.00 0.00
B 2 2.00 74.00 0.00
P 0 0.00 0.00 0.00
D 6 2.75 101.75 0.00
S 147 4700.00 7488.08 7565.66
H 0 0.00 0.00 0.00
T 4605 174220.03 378322.37 378368.19
4727 4683.75 154124.94 289.02
Other 5 5.50 310.76 310.76
-------------------------------------------------
Total 9492 183614.03 540421.90 386533.63