CMS/EIP Fiscal Report Statewide
Services beginning 10/01/2011 ending 12/31/2011 Date of Report:02/16/2012 Page: 1
List order: No List
Eligibility Filter:Program Patients
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
CASE-CASE-NON-TCM CASE MANAGEMENT 7515 5182.250000 191629.0000 36.9780
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 3079 3463.000000 0.0000 0.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 6256 6745.250000 249362.5000 36.9686
TCM-T1017TL-TARGETED CASE MANAGEMENT 19468 68531.00000 2532511.5000 36.9542
TCON-TCON-TRANSITION CONFERENCE 469 474.000000 0.0000 0.0000
Subtotal (Total Children Is Unduplicated) 19892 84395.50000 2973503.0000 35.2330
-----------------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
ASTE-ASTE-ASSISTIVE TECHNOLOGY EVAL 20 20.000000 923.0000 46.1500
AUDE-92552-PURE TONE AUDIOMETRY -AIR ONLY 20 20.000000 237.2000 11.8600
AUDE-92553-PURE TONE AUDIOMETRY AIR & BONE 1 1.000000 15.2500 15.2500
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 204 207.000000 1713.9600 8.2800
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 143 146.000000 1515.4800 10.3800
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 207 210.000000 4426.8000 21.0800
AUDE-92582-CONDITIONED PLAY AUDIOMETRY 1 2.000000 45.9200 22.9600
AUDE-92585-AUD EVOKED RESPONSE (DIAG) 4 4.000000 207.0400 51.7600
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 23 23.000000 625.3700 27.1900
AUDE-92588-OTOACOUSTIC EMISSIONS (COMP) 4 5.000000 151.5500 30.3100
AUDE-V5010-ASSESSMENT FOR HEARING AID 1 2.000000 90.0000 45.0000
AUDE-V5090-DISPENSING FEE PER HEARING AID 2 3.000000 345.0000 115.0000
BEHV-H0031HO-COMP BEHAVIORAL HEALTH ASSESSMENT 47 62.000000 7600.0000 122.5806
EVAL-EVAL-DEVELOPMENTAL EVALUATION 82 100.500000 4727.0000 47.0348
EXIT-EXIT-TRANSITION ASSESSMENT 695 1195.000000 59750.0000 50.0000
IPDEF-IPDEF_NM-F/U PSYCH & DEV EVAL BY NON-MED PROF 6 12.000000 422.0000 35.1667
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 220 373.500000 27979.5000 74.9116
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 57 86.500000 6487.5000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 46 73.000000 5339.7500 73.1473
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 138 220.000000 16542.0000 75.1909
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 249 410.000000 22746.7500 55.4799
IPDEI-IPDEI_NM-INITIAL PSYCH & DEV EVAL BY NON-MED PR 20 35.000000 1171.7500 33.4786
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 2177 3352.000000 249056.3000 74.3008
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 888 1422.500000 105435.0000 74.1195
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 533 821.500000 61330.5000 74.6567
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 2419 3817.500000 211686.0000 55.4515
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 1398 2270.499790 171803.9843 75.6679
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 168 168.000000 30502.0000 181.5595
MED-99204-OUTPATIENT VISIT, NEW, 45 MINS 7 7.000000 400.8900 57.2700
MED-99205-OUTPATIENT VISIT, NEW, 60 MINS 4 4.000000 291.1200 72.7800
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 25 25.000000 2542.1400 101.6856
MED-99215-OUTPATIENT VISIT, EST, 40 MINS 2 2.000000 100.3000 50.1500
NUTR-97802-NUTRITIONAL EVAL, INITIAL 3 2.000000 100.0000 50.0000
NUTR-97803-NUTRITIONAL EVAL, FOLLOW-UP 2 1.000000 50.0000 50.0000
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 38 38.000000 1813.5800 47.7258
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 149 152.999990 7308.5395 47.7682
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 38 38.000000 1798.0000 47.3158
PSTH-97001-EVAL BY LICENSED PT, INITIAL 104 108.000000 5149.5000 47.6806
SCREEN-T1023-INTERDISCIPLINARY SCREENING 88 89.000000 4450.0000 50.0000
SENS-V5014TS-HEARING AID REPAIR IN-OFFICE 3 4.000000 60.0000 15.0000
SPCH-92506-SPEECH EVAL BY LICENSED SLP 296 301.000000 14555.6500 48.3576
VISD-VISD-VISION EVALUATION DIAGNOSTIC 1 3.000000 225.0000 75.0000
VISF-VISF-VISION EVALUATION FUNCTIONAL 1 4.500000 225.0000 50.0000
Subtotal (Total Children Is Unduplicated) 5510 15841.99978 1031946.3238 65.1399
-----------------------------------------------------------------------------------------------------------------------
EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 66 214.000000 47833.5200 223.5211
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 872 1088.000000 54372.5000 49.9747
COIFP-COIFP-IFSP CONSULT, PRO, BY PHONE 64 50.250000 1243.7500 24.7512
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 736 1038.750000 49456.2500 47.6113
CONIP-CONIP-CONSULT, ITDS, PHONE 136 77.750000 1943.7500 25.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 205 243.250000 12241.2500 50.3237
CONOP-CONOP-CONSULT, OT, PHONE 36 17.000000 425.0000 25.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 258 292.750000 14631.2500 49.9787
CONPP-CONPP-CONSULT, PT, PHONE 53 29.750000 743.7500 25.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 631 684.750000 34357.5000 50.1752
CONSP-CONSP-CONSULT, SLP, PHONE 82 85.000000 2093.7500 24.6324
COUN-H2019HR-INDIVIDUAL/FAMILY THERAPY 5 21.000000 1539.7200 73.3200
ECE-ECE-EARLY CHILDHOOD EDUCATION 118 18680.00000 18680.0000 1.0000
EIGF-EIGF_NM-EI GROUP SESSION BY NONMED PROF 40 3872.000000 96800.0000 25.0000
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 204 3470.500000 86537.3200 24.9351
EIIF-96154-HEALTH AND BEHAVIOR INTERVENTION 45 521.250000 25477.5000 48.8777
EIIF-EIIF_NM-EI INDIVIDUAL SESSION BY NONMED PROF 19 154.500000 7725.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 6275 47256.25000 2357960.8700 49.8973
HERN-T1027SC-EI HEARING SERVICES AFTER SHINE 43 190.000000 9500.0000 50.0000
INTR-INTR-INTERPRETER 416 1758.750000 75084.6900 42.6921
OCCT-97530-OT SESSION BY LICENSED OT 1377 7874.999909 527354.2334 66.9656
OCCT-97530HM-OT SESSION BY OT ASST 121 692.250000 37585.1700 54.2942
PHY-97110-PT SESSION BY LICENSED PT 1771 9672.499970 648819.8379 67.0788
PHY-97110HM-PT SESSION BY PT ASST 82 341.250000 18749.6100 54.9439
SENS-FM-FM RECEIVER HEARING AID 1 2.000000 3275.0000 1637.5000
CMS/EIP Fiscal Report Statewide
Services beginning 10/01/2011 ending 12/31/2011 Date of Report:02/16/2012 Page: 2
List order: No List
Eligibility Filter:Program Patients
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
SENS-HA_EIP-ONE UNIT UP TO $500 PER AID 1 1.000000 500.0000 500.0000
SENS-V5050-MED HEARING AID - ANALOG/DIGITAL 2 3.000000 684.0000 228.0000
SENS-V5264-EARMOLD 5 8.000000 144.0000 18.0000
SHIN-T1027SC-INITIAL SHINE SERVICES, INDIVIDUAL 41 184.500000 9225.0000 50.0000
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 3114 19494.40000 1315012.8391 67.4559
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 76 267.500000 14530.6000 54.3200
SPL-92508-GROUP SPL SESSION PER CHILD 32 149.500000 1973.4000 13.2000
TRAN-TRAN-FAMILY TRANSPORTATION 374 1597.000000 3305.6100 2.0699
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 10076 2277134.000 1159876.6000 0.5094
VISN-EIIF_NM-EI VISION SERVICES, IND NONMED 51 514.750000 25737.5000 50.0000
VISN-T1027SC-EI VISION SERVICES, INDIVIDUAL 4 29.000000 1450.0000 50.0000
Subtotal (Total Children Is Unduplicated) 11794 2397711.150 6666870.7704 2.7805
-----------------------------------------------------------------------------------------------------------------------
Total 2497948.649658 10672320.0942 4.2724
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 20874
-----------------------------------------------------------------------------------------------------------------------
Center 01
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 3 2.500000 92.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 1580 1182.000000 46367.5000 0.0000
P 9113 210625.000000 378502.6700 378493.4200
D 238 207.000000 10390.5000 0.0000
S 22 26.000000 3025.0000 0.0000
H 51 67.000000 5400.0000 0.0000
T 2845 102246.000000 142798.3710 142802.1200
7698 16592.750000 406570.3480 0.0000
Other 711 11120.000000 53128.1700 0.0000
---------------------------------------------------------
Total 22261 342068.250000 1046275.0590 521295.5400
Center 02
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 3 3.000000 111.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 1085 865.250000 31746.0000 0.0000
P 0 0.000000 0.0000 0.0000
D 0 0.000000 0.0000 0.0000
S 2 3.750000 138.7500 0.0000
H 0 0.000000 0.0000 0.0000
T 779 36414.250000 49030.0300 49030.0300
2199 40185.000000 102658.7700 3275.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 4068 77471.250000 183684.5500 52305.0300
Center 03
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 60 32.500000 1458.2500 0.0000
P 6644 49426.500000 184415.2100 184408.9600
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 4652 2566.000000 82347.9200 82347.9200
7486 88936.000000 212748.7000 0.0000
Other 160 159.250000 2563.1500 0.0000
---------------------------------------------------------
Total 19002 141120.250000 483533.2300 266756.8800
Center 04
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 1 0.750000 27.7500 0.0000
U 0 0.000000 0.0000 0.0000
B 2403 2702.750000 102366.7500 0.0000
P 5457 149993.250000 330703.5200 325530.9500
D 23 26.000000 999.5000 148.0000
S 0 0.000000 0.0000 0.0000
H 1670 5836.500000 288832.6800 288507.5200
T 0 0.000000 0.0000 0.0000
5420 12028.250000 407017.0400 0.0000
Other 54 115.500000 7621.2000 7280.8000
---------------------------------------------------------
Total 15028 170703.000000 1137568.4400 621467.2700
Center 05
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 2977 1755.750000 67568.3900 0.0000
P 3186 95307.500000 136807.9700 136807.9700
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
4124 19822.500000 112373.8500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 10287 116885.750000 316750.2100 136807.9700
Center 06
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 2717 1974.500000 73056.5000 0.0000
P 4397 46144.500000 114780.1200 81526.3700
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
12843 63594.750000 425201.0900 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 19957 111713.750000 613037.7100 81526.3700
Center 07
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 15 8.750000 323.7500 0.0000
U 0 0.000000 0.0000 0.0000
B 144 86.250000 3191.2500 0.0000
P 7639 156981.250000 351163.6100 351154.3600
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
7952 13089.750000 339735.1900 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 15750 170166.000000 694413.8000 351154.3600
Center 09
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 3 1.750000 64.7500 0.0000
U 0 0.000000 0.0000 0.0000
B 6049 6091.750000 273080.4800 0.0000
P 14876 264609.500000 782756.5100 782889.5450
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
2802 11185.500000 407924.1000 831.4600
Other 3 1.750000 64.7500 0.0000
---------------------------------------------------------
Total 23733 281890.250000 1463890.5900 783721.0050
Center 10
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 47 24.250000 1011.2500 0.0000
U 0 0.000000 0.0000 0.0000
B 1575 1648.500000 92813.5000 6669.2500
P 13117 188414.250000 574241.3500 566755.1000
D 14 14.000000 518.0000 18740.2500
S 91 77.250000 2858.2500 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
8510 10482.500000 528807.0700 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 23354 200660.750000 1200249.4200 592164.6000
Center 51
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 2 2.000000 150.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 4408 3176.250000 122488.6700 0.0000
P 2118 112546.250000 153064.8400 153032.8400
D 17 15.750000 880.2900 0.0000
S 0 0.000000 0.0000 0.0000
H 3 3.500000 129.5000 0.0000
T 0 0.000000 0.0000 0.0000
4599 14697.750000 282563.8200 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 11147 130441.500000 559277.1200 153032.8400
Center 52
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 564 458.750000 24022.6900 0.0000
P 2440 20046.050212 82396.0500 82396.0500
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 90 166.250000 10839.6400 0.0000
T 0 0.000000 0.0000 0.0000
5301 83786.599792 281001.7505 0.0000
Other 42 141.250000 5702.9900 0.0000
---------------------------------------------------------
Total 8437 104598.900004 403963.1205 82396.0500
Center 53
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 8 6.000000 222.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 60 48.000000 1928.0000 9.2500
P 4716 52063.250000 159576.7300 159711.1800
D 231 252.500000 14087.9000 0.0000
S 0 0.000000 0.0000 0.0000
H 1257 49529.512670 53249.1400 53249.1400
T 918 694.500000 20840.2500 20840.2500
7274 84586.986990 324684.5954 200.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 14464 187180.749660 574588.6154 234009.8200
Center 54
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 121 86.500000 3200.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 61 55.500000 3227.6200 0.0000
P 2353 89818.454260 114731.0795 114731.0800
D 25 29.000000 1562.0000 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
13507 87700.045730 498647.9398 110.9900
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 16067 177689.499990 621369.1393 114842.0700
Center 55
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 28 30.500000 1100.7500 0.0000
P 5308 61612.193166 173371.2200 173258.7200
D 36 36.250000 1968.2500 0.0000
S 0 0.000000 0.0000 0.0000
H 3 4.500000 337.5000 0.0000
T 1643 24069.441636 50590.2100 50590.2100
4446 3831.115202 191597.3100 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 11464 89584.000004 418965.2400 223848.9300
Center 57
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 83 88.500000 3274.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 1242 1310.500000 58766.7500 0.0000
P 2080 2028.315500 75459.4900 75380.0700
D 15 13.000000 481.0000 0.0000
S 45 1289.500000 2778.1400 2778.1400
H 0 0.000000 0.0000 0.0000
T 3267 159107.684500 269359.8800 269359.8800
5754 31830.500000 543309.6200 343390.3600
Other 15 106.750000 1324.4700 1324.4700
---------------------------------------------------------
Total 12501 195774.750000 954753.8500 692232.9200