CMS/EIP Fiscal Report Statewide
Services beginning 07/01/2010 ending 09/30/2010 Date of Report:11/17/2010 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 8022 5555.250000 205498.0000 36.9917
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 6070 6938.000000 0.0000 0.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 6311 7343.500000 271450.5000 36.9647
TCM-T1017TL-TARGETED CASE MANAGEMENT 21270 70706.25000 2613812.5000 36.9672
TCON-TCON-TRANSITION CONFERENCE 883 886.000000 0.0000 0.0000
Subtotal (Total Children Is Unduplicated) 21927 91429.00000 3090761.0000 33.8050
-----------------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
ASTE-ASTE-ASSISTIVE TECHNOLOGY EVAL 9 10.000000 461.5000 46.1500
AUDE-92552-PURE TONE AUDIOMETRY -AIR ONLY 29 30.000000 325.4400 10.8480
AUDE-92553-PURE TONE AUDIOMETRY AIR & BONE 5 5.000000 81.0600 16.2120
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 218 223.000000 2025.6100 9.0835
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 184 190.000000 2076.1800 10.9273
AUDE-92568-ACOUSTIC REFLEX TESTING (MEMR) 2 2.000000 16.8800 8.4400
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 219 225.000000 4904.9200 21.7996
AUDE-92585-AUD EVOKED RESPONSE (DIAG) 7 8.000000 377.9100 47.2388
AUDE-92586-AUD EVOKED RESPONSE (SCREEN) 1 1.000000 30.4300 30.4300
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 42 43.000000 1187.7600 27.6223
AUDE-92588-OTOACOUSTIC EMISSIONS (COMP) 27 29.000000 1023.9800 35.3097
AUDE-V5010-ASSESSMENT FOR HEARING AID 5 5.000000 226.8000 45.3600
AUDE-V5090-DISPENSING FEE PER HEARING AID 1 2.000000 212.0000 106.0000
BEHV-H0031HO-COMP BEHAVIORAL HEALTH ASSESSMENT 33 41.000000 4875.0000 118.9024
EVAL-EVAL-DEVELOPMENTAL EVALUATION 70 86.500000 4735.0000 54.7399
EXIT-EXIT-TRANSITION ASSESSMENT 753 1292.250000 64726.5000 50.0882
IPDEF-IPDEF_NM-F/U PSYCH & DEV EVAL BY NON-MED PROF 4 5.000000 211.0000 42.2000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 229 385.000000 28677.2500 74.4864
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 52 73.500000 5312.5000 72.2789
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 54 69.000000 5100.0000 73.9130
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 163 254.500000 19344.2500 76.0088
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 231 367.000000 20332.5000 55.4019
IPDEI-IPDEI_NM-INITIAL PSYCH & DEV EVAL BY NON-MED PR 41 71.999990 3623.2494 50.3229
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 2511 3731.105330 278116.5798 74.5400
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 729 1117.500000 83392.0000 74.6237
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 770 1116.499890 83258.9618 74.5714
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 2718 4487.499911 250200.7750 55.7550
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 1719 2936.500000 224445.1200 76.4329
MED-99202-OUTPATIENT VISIT, NEW, 20 MINS 1 1.000000 27.2200 27.2200
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 169 169.000000 29531.0000 174.7396
MED-99204-OUTPATIENT VISIT, NEW, 45 MINS 13 13.000000 744.5100 57.2700
MED-99205-OUTPATIENT VISIT, NEW, 60 MINS 13 13.000000 946.1400 72.7800
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 32 32.000000 3360.0000 105.0000
MED-99215-OUTPATIENT VISIT, EST, 40 MINS 11 11.000000 551.6500 50.1500
NUTR-97802-NUTRITIONAL EVAL, INITIAL 4 3.750000 187.5000 50.0000
NUTR-NUTR-UNSPECIFIED NUTRITIONAL EVAL 1 1.000000 50.0000 50.0000
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 72 74.000000 3531.7200 47.7259
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 226 232.210511 11231.3897 48.3673
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 37 37.000000 1780.8500 48.1311
PSTH-97001-EVAL BY LICENSED PT, INITIAL 201 206.000000 9897.9500 48.0483
SCREEN-T1023-INTERDISCIPLINARY SCREENING 206 207.000000 10350.0000 50.0000
SENS-V5014TS-HEARING AID REPAIR IN-OFFICE 2 3.000000 59.7600 19.9200
SPCH-92506-SPEECH EVAL BY LICENSED SLP 615 631.000000 31299.1300 49.6024
VISF-VISF-VISION EVALUATION FUNCTIONAL 3 5.000000 487.5000 97.5000
Subtotal (Total Children Is Unduplicated) 6553 18446.81563 1193337.4757 64.6907
-----------------------------------------------------------------------------------------------------------------------
EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 69 231.000000 50821.4200 220.0061
AUD-92630-AUD REHAB PRELING HEARING LOSS 6 23.000000 1293.0500 56.2196
AUD-HA_FUP-AUDIOLOGY SERVICES 5 8.000000 316.3800 39.5475
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 854 1190.500000 59500.0000 49.9790
COIFP-COIFP-IFSP CONSULT, PRO, BY PHONE 41 104.250000 2618.7500 25.1199
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 553 650.500000 31542.0000 48.4889
CONIP-CONIP-CONSULT, ITDS, PHONE 95 103.750000 1356.2500 13.0723
CONOF-CONOF-CONSULT, OT, FACE TO FACE 199 222.500000 11011.2500 49.4888
CONOP-CONOP-CONSULT, OT, PHONE 40 25.250000 618.7500 24.5050
CONPF-CONPF-CONSULT, PT, FACE TO FACE 192 205.250000 10262.5000 50.0000
CONPP-CONPP-CONSULT, PT, PHONE 29 14.250000 356.2500 25.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 575 601.250000 30062.5000 50.0000
CONSP-CONSP-CONSULT, SLP, PHONE 63 29.750000 743.7500 25.0000
COUN-H2019HR-INDIVIDUAL/FAMILY THERAPY 1 9.000000 660.7800 73.4200
ECE-ECE-EARLY CHILDHOOD EDUCATION 116 7359.000000 67587.5000 9.1843
EIGF-EIGF_NM-EI GROUP SESSION BY NONMED PROF 128 7754.000000 193796.0000 24.9930
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 156 2349.750000 58743.7500 25.0000
EIIF-90847-FAMILY PSYCHOTHERAPY WITH PATIENT 1 3.000000 150.0000 50.0000
EIIF-96154-HEALTH AND BEHAVIOR INTERVENTION 78 606.750000 30337.5000 50.0000
EIIF-EIIF_NM-EI INDIVIDUAL SESSION BY NONMED PROF 110 433.750000 21285.3400 49.0728
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 6043 45047.00000 2250998.8000 49.9700
HERN-EIIF_NM-EI HEARING SERVICES AFTER SHINE NONMED 7 4.750000 237.5000 50.0000
HERN-T1027SC-EI HEARING SERVICES AFTER SHINE 33 112.500000 5625.0000 50.0000
INTR-INTR-INTERPRETER 230 1330.250000 53153.0000 39.9572
CMS/EIP Fiscal Report Statewide
Services beginning 07/01/2010 ending 09/30/2010 Date of Report:11/17/2010 Page: 2
Eligibility Filter:Program Patients
List order: No List
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
OCCT-97530-OT SESSION BY LICENSED OT 1871 10707.81533 717817.5687 67.0368
OCCT-97530HM-OT SESSION BY OT ASST 140 718.840942 38927.7100 54.1534
PHY-97110-PT SESSION BY LICENSED PT 2207 11888.98157 786815.8597 66.1803
PHY-97110HM-PT SESSION BY PT ASST 80 354.250000 18545.2800 52.3508
RSPT-RSPT-RESPITE 2 82.500000 340.0000 4.1212
SENS-HA_INS-SENSORY AID INSURANCE PER EAR 1 2.000000 130.0000 65.0000
SENS-V5014-HEARING AID REPAIR BY MANUFACTURER 1 7.000000 392.9100 56.1300
SENS-V5050-MED HEARING AID - ANALOG/DIGITAL 1 2.000000 456.0000 228.0000
SENS-V5264-EARMOLD 6 10.000000 183.6000 18.3600
SHIN-T1027SC-INITIAL SHINE SERVICES, INDIVIDUAL 29 104.750000 5237.5000 50.0000
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 5038 31430.56974 2102654.7871 66.8984
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 188 682.000000 37046.2400 54.3200
SPL-92508-GROUP SPL SESSION PER CHILD 72 290.000000 3828.0000 13.2000
TRAN-TRAN-FAMILY TRANSPORTATION 384 484.000000 6781.2100 14.0108
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 10310 2342040.000 1238328.1940 0.5287
VISN-EIIF_NM-EI VISION SERVICES, IND NONMED 42 226.250000 11312.5000 50.0000
VISN-T1027SC-EI VISION SERVICES, INDIVIDUAL 10 40.000000 2000.0000 50.0000
Subtotal (Total Children Is Unduplicated) 12866 2467489.958 7853875.3795 3.1829
-----------------------------------------------------------------------------------------------------------------------
Total 2577365.773219 12137973.8552 4.7094
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 23052
-----------------------------------------------------------------------------------------------------------------------
Center 01
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 920 653.500000 28005.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 5900 4339.750000 175698.2500 0.0000
P 7267 176889.750000 294282.1900 292031.2400
D 198 220.000000 13018.0000 0.0000
S 190 134.750000 5886.7500 0.0000
H 10 17.500000 1275.0000 0.0000
T 3566 105678.550000 164004.5500 164907.0500
8898 18955.490000 407909.3600 0.0000
Other 2727 16433.750000 166123.4800 16164.2800
---------------------------------------------------------
Total 29676 323323.040000 1256202.5800 473102.5700
Center 02
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 6 4.000000 148.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 738 547.000000 20155.7500 0.0000
P 2 1.000000 37.0000 0.0000
D 0 0.000000 0.0000 0.0000
S 4 2.250000 83.2500 0.0000
H 0 0.000000 0.0000 0.0000
T 322 14492.750000 21029.1000 21029.1000
3352 61949.250000 162256.6900 605.2000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 4424 76996.250000 203709.7900 21634.3000
Center 03
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 15 12.500000 462.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 219 149.000000 5665.0000 9.2500
P 8189 89253.500000 271032.5800 271026.8300
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 4316 2762.750000 95978.2400 95978.2400
4386 41457.000000 136367.5810 0.0000
Other 135 134.250000 2158.4600 0.0000
---------------------------------------------------------
Total 17260 133769.000000 511664.3610 367014.3200
Center 04
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 1 0.750000 27.7500 0.0000
U 0 0.000000 0.0000 0.0000
B 1944 2024.750000 78354.7500 0.0000
P 5760 150650.250000 314890.9800 308870.1300
D 111 116.750000 11080.7500 0.0000
S 0 0.000000 0.0000 0.0000
H 1806 5985.750000 297239.4300 297025.0100
T 0 0.000000 0.0000 0.0000
5794 14383.250000 437367.5900 40.0000
Other 185 471.000000 31228.4400 31004.3400
---------------------------------------------------------
Total 15601 173632.500000 1170189.6900 636939.4800
Center 05
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 2991 1758.250000 67368.9500 0.0000
P 2395 71890.044322 105616.4000 105616.4000
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
6028 43343.628058 196510.1000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 11414 116991.922380 369495.4500 105616.4000
Center 06
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 11 5.750000 212.7500 0.0000
U 0 0.000000 0.0000 0.0000
B 4223 2825.250000 104515.7500 0.0000
P 5055 61734.250000 135611.0000 135482.3600
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
19396 91793.750000 604765.7100 27.7500
Other 1 0.500000 18.5000 0.0000
---------------------------------------------------------
Total 28686 156359.500000 845123.7100 135510.1100
Center 07
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 99 84.750000 3135.7500 0.0000
U 0 0.000000 0.0000 0.0000
B 2294 1564.500000 63153.7500 0.0000
P 5796 146779.500000 398038.6000 393804.6000
D 20 31.500000 2312.5000 0.0000
S 49 41.250000 1526.2500 0.0000
H 0 0.000000 0.0000 0.0000
T 1 1.000000 37.0000 0.0000
10539 16287.500000 443506.0900 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 18798 164790.000000 911709.9400 393804.6000
Center 09
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 12 11.500000 462.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 5712 5741.000000 260479.2800 0.0000
P 11044 199184.750000 604003.7900 604268.0800
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 5974 106339.250000 336022.9100 335958.1600
3876 17208.750000 504884.2600 1304.1900
Other 2 1.500000 55.5000 0.0000
---------------------------------------------------------
Total 26620 328486.750000 1705908.2400 941530.4300
Center 10
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 19 9.000000 333.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 423 250.750000 9409.7500 0.0000
P 12378 154423.250000 579133.3400 579133.3400
D 41 28.250000 1309.7500 1309.7500
S 112 71.250000 2636.2500 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
10816 12303.750000 597367.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 23789 167086.250000 1190189.0900 580443.0900
Center 51
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 4 3.250000 120.2500 0.0000
U 0 0.000000 0.0000 0.0000
B 4237 3012.250000 113893.9000 0.0000
P 2774 130050.250000 217501.8400 217433.1800
D 28 18.000000 707.3800 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
5082 6483.500000 308098.4200 22.5000
Other 1 0.500000 18.5000 0.0000
---------------------------------------------------------
Total 12126 139567.750000 640340.2900 217455.6800
Center 52
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 20 10.750000 546.1500 0.0000
P 4274 75018.459387 179633.2697 179422.2700
D 3 2.250000 109.2500 0.0000
S 21 10.750000 428.6300 0.0000
H 27 49.500000 3280.0000 0.0000
T 0 0.000000 0.0000 0.0000
5937 66999.448812 305719.2723 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 10282 142091.158199 489716.5720 179422.2700
Center 53
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 97 107.500000 4255.5000 311.0000
U 0 0.000000 0.0000 0.0000
B 1346 1296.000000 54015.7500 0.0000
P 712 852.053285 42945.2159 41295.2200
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 1443 45387.716930 72846.1396 72829.0200
T 1625 33169.000000 62389.4900 62389.4900
6005 59198.690082 286979.0902 37.5000
Other 5 35.000000 237.0000 0.0000
---------------------------------------------------------
Total 11233 140045.960297 523668.1857 176862.2300
Center 54
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 25 18.250000 760.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 3189 2353.500000 98726.0800 0.0000
P 5520 178004.390000 349797.1800 349665.3000
D 61 35.750000 1420.5000 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
6807 57790.330000 369982.8264 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 15602 238202.220000 820686.5864 349665.3000
Center 55
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 15 11.250000 416.2500 0.0000
U 0 0.000000 0.0000 0.0000
B 41 50.250000 3227.2500 0.0000
P 5463 61430.206817 168025.5730 167971.3200
D 36 39.000000 1927.7500 0.0000
S 4 5.250000 194.2500 0.0000
H 15 22.000000 3750.0000 0.0000
T 2167 33491.777221 64072.2571 64072.2600
5960 4866.988305 247620.8200 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 13701 99916.722343 489234.1501 232043.5800
Center 57
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 16 19.500000 721.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 2815 3053.250000 126605.2500 0.0000
P 8 9.500000 563.7200 563.7200
D 6 2.750000 101.7500 0.0000
S 179 6044.500000 13865.0800 13596.6200
H 0 0.000000 0.0000 0.0000
T 3870 147210.750000 327339.9600 327304.3200
6385 18466.500000 537861.5600 374361.8400
Other 44 1300.000000 3076.4000 3076.4000
---------------------------------------------------------
Total 13323 176106.750000 1010135.2200 718902.9000