CMS/EIP Fiscal Report Statewide
Services beginning 07/01/2010 ending 09/30/2010 Date of Report:11/17/2010 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 8005 5537.500000 204841.2500 36.9916
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 6059 6917.000000 0.0000 0.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 6311 7311.000000 270248.0000 36.9646
TCM-T1017TL-TARGETED CASE MANAGEMENT 8918 27584.25000 1019620.2500 36.9639
TCON-TCON-TRANSITION CONFERENCE 882 885.000000 0.0000 0.0000
Subtotal (Total Children Is Unduplicated) 17076 48234.75000 1494709.5000 30.9882
-----------------------------------------------------------------------------------------------------------------------
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 15 15.000000 164.4300 10.9620
AUDE-92553-PURE TONE AUDIOMETRY AIR & BONE 3 3.000000 48.9000 16.3000
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 53 54.000000 470.6600 8.7159
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 55 55.000000 587.2800 10.6778
AUDE-92568-ACOUSTIC REFLEX TESTING (MEMR) 2 2.000000 16.8800 8.4400
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 57 58.000000 1233.7700 21.2719
AUDE-92585-AUD EVOKED RESPONSE (DIAG) 4 4.000000 166.1400 41.5350
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 17 17.000000 468.4100 27.5535
AUDE-92588-OTOACOUSTIC EMISSIONS (COMP) 10 10.000000 315.4900 31.5490
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 22 24.000000 2750.0000 114.5833
EVAL-EVAL-DEVELOPMENTAL EVALUATION 67 77.000000 4260.0000 55.3247
EXIT-EXIT-TRANSITION ASSESSMENT 741 1265.250000 63326.5000 50.0506
IPDEF-IPDEF_NM-F/U PSYCH & DEV EVAL BY NON-MED PROF 1 1.000000 55.5000 55.5000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 42 73.678400 5527.8800 75.0271
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 9 13.000000 975.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 10 12.500000 937.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 55 71.000000 5444.2500 76.6796
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 65 104.500000 5799.7500 55.5000
IPDEI-IPDEI_NM-INITIAL PSYCH & DEV EVAL BY NON-MED PR 30 53.801800 2929.2499 54.4452
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 621 904.240364 66152.0798 73.1576
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 139 215.324900 15928.9300 73.9763
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 128 198.478730 14436.2148 72.7343
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 768 1340.927309 74399.7156 55.4838
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 545 931.607733 71246.0800 76.4765
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 9 9.000000 653.5000 72.6111
MED-99204-OUTPATIENT VISIT, NEW, 45 MINS 1 1.000000 57.2700 57.2700
MED-99205-OUTPATIENT VISIT, NEW, 60 MINS 7 7.000000 509.4600 72.7800
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 4 4.000000 420.0000 105.0000
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 43 43.000000 2028.2200 47.1679
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 107 105.818351 5101.2900 48.2080
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 17 16.500000 778.1200 47.1588
PSTH-97001-EVAL BY LICENSED PT, INITIAL 69 68.500000 3228.4500 47.1307
SCREEN-T1023-INTERDISCIPLINARY SCREENING 108 108.000000 5400.0000 50.0000
SENS-V5014TS-HEARING AID REPAIR IN-OFFICE 1 2.000000 30.0000 15.0000
SPCH-92506-SPEECH EVAL BY LICENSED SLP 302 305.080000 14706.7300 48.2061
VISF-VISF-VISION EVALUATION FUNCTIONAL 2 4.250000 450.0000 105.8824
Subtotal (Total Children Is Unduplicated) 2827 6200.207587 372141.4501 60.0208
-----------------------------------------------------------------------------------------------------------------------
EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 64 180.000000 38481.1500 213.7842
AUD-92630-AUD REHAB PRELING HEARING LOSS 5 19.000000 1009.3600 53.1242
AUD-HA_FUP-AUDIOLOGY SERVICES 3 3.000000 150.0000 50.0000
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 845 1173.500000 58650.0000 49.9787
COIFP-COIFP-IFSP CONSULT, PRO, BY PHONE 40 103.750000 2593.7500 25.0000
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 541 636.250000 30829.5000 48.4550
CONIP-CONIP-CONSULT, ITDS, PHONE 95 103.500000 1350.0000 13.0435
CONOF-CONOF-CONSULT, OT, FACE TO FACE 198 221.000000 10936.2500 49.4853
CONOP-CONOP-CONSULT, OT, PHONE 40 25.250000 618.7500 24.5050
CONPF-CONPF-CONSULT, PT, FACE TO FACE 186 200.750000 10037.5000 50.0000
CONPP-CONPP-CONSULT, PT, PHONE 28 14.000000 350.0000 25.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 557 577.000000 28850.0000 50.0000
CONSP-CONSP-CONSULT, SLP, PHONE 63 29.750000 743.7500 25.0000
ECE-ECE-EARLY CHILDHOOD EDUCATION 3 207.000000 2587.5000 12.5000
EIGF-EIGF_NM-EI GROUP SESSION BY NONMED PROF 11 32.000000 746.0000 23.3125
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 39 198.000000 4950.0000 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 48 169.500000 8072.8400 47.6274
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 2394 17887.67000 893459.5300 49.9483
HERN-T1027SC-EI HEARING SERVICES AFTER SHINE 11 30.000000 1500.0000 50.0000
INTR-INTR-INTERPRETER 230 1328.250000 53053.0000 39.9420
OCCT-97530-OT SESSION BY LICENSED OT 832 4699.205141 307011.5697 65.3327
OCCT-97530HM-OT SESSION BY OT ASST 66 314.147173 16951.8800 53.9616
PHY-97110-PT SESSION BY LICENSED PT 842 4254.126879 271836.9100 63.8996
PHY-97110HM-PT SESSION BY PT ASST 33 153.000000 7613.3800 49.7607
RSPT-RSPT-RESPITE 2 82.500000 340.0000 4.1212
CMS/EIP Fiscal Report Statewide
Services beginning 07/01/2010 ending 09/30/2010 Date of Report:11/17/2010 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-HA_INS-SENSORY AID INSURANCE PER EAR 1 2.000000 130.0000 65.0000
SENS-V5014-HEARING AID REPAIR BY MANUFACTURER 1 2.000000 181.3800 90.6900
SENS-V5050-MED HEARING AID - ANALOG/DIGITAL 1 2.000000 456.0000 228.0000
SENS-V5264-EARMOLD 4 7.000000 129.6000 18.5143
SHIN-T1027SC-INITIAL SHINE SERVICES, INDIVIDUAL 15 51.000000 2550.0000 50.0000
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 2842 17754.64419 1170394.8071 65.9205
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 145 454.500000 24688.4400 54.3200
SPL-92508-GROUP SPL SESSION PER CHILD 11 71.000000 937.2000 13.2000
TRAN-TRAN-FAMILY TRANSPORTATION 384 484.000000 6781.2100 14.0108
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 10284 2334177.000 1217530.8940 0.5216
VISN-EIIF_NM-EI VISION SERVICES, IND NONMED 8 29.000000 1450.0000 50.0000
VISN-T1027SC-EI VISION SERVICES, INDIVIDUAL 5 16.000000 800.0000 50.0000
Subtotal (Total Children Is Unduplicated) 11809 2386302.043 4209239.6508 1.7639
-----------------------------------------------------------------------------------------------------------------------
Total 2440737.000973 6076090.6009 2.4894
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 19817
-----------------------------------------------------------------------------------------------------------------------
Center 01
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 0 0.000000 0.0000 0.0000
P 5960 175901.250000 250827.7400 250855.9900
D 3 1.500000 55.5000 0.0000
S 9 12.750000 702.7500 0.0000
H 0 0.000000 0.0000 0.0000
T 3565 105676.550000 163930.5500 164907.0500
6458 14371.750000 148519.1000 0.0000
Other 921 14500.250000 41205.4700 13289.2800
---------------------------------------------------------
Total 16916 310464.050000 605241.1100 429052.3200
Center 02
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 0 0.000000 0.0000 0.0000
P 0 0.000000 0.0000 0.0000
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 322 14492.750000 21029.1000 21029.1000
3015 61395.000000 131556.1900 605.2000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 3337 75887.750000 152585.2900 21634.3000
Center 03
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 0 0.000000 0.0000 0.0000
P 5389 87363.500000 195939.8100 195939.8100
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
4380 41451.000000 135960.3010 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 14085 131577.250000 427878.3510 291918.0500
Center 04
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 0 0.000000 0.0000 0.0000
P 3096 147870.250000 204052.4800 200953.1100
D 65 70.750000 2890.7500 0.0000
S 0 0.000000 0.0000 0.0000
H 13 255.000000 1029.4200 1029.4200
T 0 0.000000 0.0000 0.0000
4759 3976.500000 126663.0000 40.0000
Other 4 4.000000 271.5200 271.5200
---------------------------------------------------------
Total 7937 152176.500000 334907.1700 202294.0500
Center 05
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 0 0.000000 0.0000 0.0000
P 2222 71710.794322 95712.9000 95712.9000
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
4420 42084.008338 131175.3000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 6642 113794.802660 226888.2000 95712.9000
Center 06
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 0 0.000000 0.0000 0.0000
P 4970 61679.000000 133180.7500 133052.1100
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
13938 87174.500000 330952.0800 27.7500
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 18908 148853.500000 464132.8300 133079.8600
Center 07
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 0 0.000000 0.0000 0.0000
P 3306 145050.250000 324740.0500 324740.0500
D 1 1.000000 75.0000 0.0000
S 16 16.000000 592.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
8923 11253.250000 187855.8600 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 12246 156320.500000 513262.9100 324740.0500
Center 09
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 0 0.000000 0.0000 0.0000
P 10526 198737.000000 585744.7200 585717.6200
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
347 9643.250000 28814.9600 1304.1900
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 16847 314719.500000 950582.5900 922979.9700
Center 10
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 0 0.000000 0.0000 0.0000
P 4471 148878.250000 341198.0900 341198.0900
D 41 28.250000 1309.7500 1309.7500
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
7086 5260.250000 162768.5000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 11598 154166.750000 505276.3400 342507.8400
Center 51
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 0 0.000000 0.0000 0.0000
P 2734 129737.250000 212050.0800 212074.9600
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
3627 2910.500000 89496.2600 22.5000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 6389 132665.750000 302253.7200 212097.4600
Center 52
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 0 0.000000 0.0000 0.0000
P 1448 73033.709387 88982.2997 88996.3000
D 3 2.250000 109.2500 0.0000
S 4 1.000000 37.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
4576 59622.000586 124250.9500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 6031 132658.959973 213379.4997 88996.3000
Center 53
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 0 0.000000 0.0000 0.0000
P 3 6.000000 333.0000 333.0000
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
3007 56260.229572 120665.1805 37.5000
Other 1 0.250000 9.2500 0.0000
---------------------------------------------------------
Total 6079 134823.196502 256243.0601 135589.0100
Center 54
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 0 0.000000 0.0000 0.0000
P 3066 176212.890000 274411.7500 274402.5000
D 48 28.750000 1148.5000 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
4898 53231.500000 138239.2700 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 8012 229473.140000 413799.5200 274402.5000
Center 55
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 0 0.000000 0.0000 0.0000
P 3846 59946.706817 110683.8230 110683.8200
D 36 39.000000 1927.7500 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 2167 33491.777221 64072.2571 64072.2600
2128 1763.367800 47764.9000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 8177 95240.851838 224448.7301 174756.0800
Center 57
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 0 0.000000 0.0000 0.0000
P 0 0.000000 0.0000 0.0000
D 6 2.750000 101.7500 0.0000
S 169 5882.500000 13120.0600 12871.6000
H 0 0.000000 0.0000 0.0000
T 3863 147197.750000 326635.0600 326599.4200
3946 4145.000000 144678.6100 462.5000
Other 9 686.500000 675.8000 675.8000
---------------------------------------------------------
Total 7993 157914.500000 485211.2800 340609.3200