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
Payclass Filters:GR
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 7511 5180.500000 191564.2500 36.9779
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 3078 3462.000000 0.0000 0.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 6255 6741.000000 249205.2500 36.9686
TCM-T1017TL-TARGETED CASE MANAGEMENT 7325 24369.25000 900913.5000 36.9693
TCON-TCON-TRANSITION CONFERENCE 469 474.000000 0.0000 0.0000
Subtotal (Total Children Is Unduplicated) 14726 40226.75000 1341683.0000 33.3530
-----------------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
ASTE-ASTE-ASSISTIVE TECHNOLOGY EVAL 16 16.000000 729.0000 45.5625
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) 40 40.000000 331.2000 8.2800
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 40 41.000000 425.5800 10.3800
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 43 44.000000 927.5200 21.0800
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 15 15.000000 407.8500 27.1900
AUDE-92588-OTOACOUSTIC EMISSIONS (COMP) 1 1.000000 30.3100 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 21 25.000000 2975.0000 119.0000
EVAL-EVAL-DEVELOPMENTAL EVALUATION 80 98.000000 4602.0000 46.9592
EXIT-EXIT-TRANSITION ASSESSMENT 689 1185.000000 59250.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 40 66.666700 4967.0000 74.5050
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 8 7.500000 562.5000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 8 12.000000 789.7500 65.8125
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 38 40.000000 3079.5000 76.9875
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 45 75.500000 4190.2500 55.5000
IPDEI-IPDEI_NM-INITIAL PSYCH & DEV EVAL BY NON-MED PR 1 1.500000 83.2500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 498 700.160500 50151.6900 71.6288
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 126 203.092000 14201.2600 69.9253
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 103 139.000000 10143.0000 72.9712
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 577 966.500000 53591.2500 55.4488
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 493 656.794331 50851.0748 77.4231
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 2 2.000000 225.5000 112.7500
MED-99204-OUTPATIENT VISIT, NEW, 45 MINS 2 2.000000 114.5400 57.2700
MED-99205-OUTPATIENT VISIT, NEW, 60 MINS 1 1.000000 72.7800 72.7800
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 1 1.000000 22.1400 22.1400
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 14 14.000000 649.5800 46.3986
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 66 64.946280 3037.8196 46.7743
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 15 14.250000 642.2000 45.0667
PSTH-97001-EVAL BY LICENSED PT, INITIAL 38 40.000000 1864.0000 46.6000
SCREEN-T1023-INTERDISCIPLINARY SCREENING 46 46.000000 2300.0000 50.0000
SENS-V5014TS-HEARING AID REPAIR IN-OFFICE 2 3.000000 45.0000 15.0000
SPCH-92506-SPEECH EVAL BY LICENSED SLP 134 131.861400 6329.6000 48.0019
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) 2344 4690.271211 278879.5944 59.4592
-----------------------------------------------------------------------------------------------------------------------
EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 52 146.000000 32168.7700 220.3340
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 866 1073.500000 53647.5000 49.9744
COIFP-COIFP-IFSP CONSULT, PRO, BY PHONE 64 50.250000 1243.7500 24.7512
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 733 1034.250000 49231.2500 47.6009
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 35 16.000000 400.0000 25.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 257 291.500000 14567.8400 49.9754
CONPP-CONPP-CONSULT, PT, PHONE 52 28.750000 718.7500 25.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 622 673.000000 33770.0000 50.1783
CONSP-CONSP-CONSULT, SLP, PHONE 81 84.000000 2068.7500 24.6280
COUN-H2019HR-INDIVIDUAL/FAMILY THERAPY 5 21.000000 1539.7200 73.3200
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 81 367.500000 8978.8200 24.4322
EIIF-96154-HEALTH AND BEHAVIOR INTERVENTION 43 302.250000 15112.5000 50.0000
EIIF-EIIF_NM-EI INDIVIDUAL SESSION BY NONMED PROF 4 35.000000 1750.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 2232 16304.78020 810051.3200 49.6818
HERN-T1027SC-EI HEARING SERVICES AFTER SHINE 6 25.000000 1250.0000 50.0000
INTR-INTR-INTERPRETER 413 1745.750000 74824.6900 42.8611
OCCT-97530-OT SESSION BY LICENSED OT 594 3297.033124 216263.5378 65.5934
OCCT-97530HM-OT SESSION BY OT ASST 66 388.720000 20678.4100 53.1962
PHY-97110-PT SESSION BY LICENSED PT 700 3820.714613 250108.2994 65.4611
PHY-97110HM-PT SESSION BY PT ASST 24 107.788800 5805.9500 53.8641
SENS-FM-FM RECEIVER HEARING AID 1 2.000000 3275.0000 1637.5000
SENS-V5050-MED HEARING AID - ANALOG/DIGITAL 2 3.000000 684.0000 228.0000
SENS-V5264-EARMOLD 4 7.000000 126.0000 18.0000
SHIN-T1027SC-INITIAL SHINE SERVICES, INDIVIDUAL 18 115.500000 5775.0000 50.0000
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 1728 10746.09533 719241.8810 66.9305
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 50 190.131800 10327.9600 54.3200
SPL-92508-GROUP SPL SESSION PER CHILD 1 2.000000 26.4000 13.2000
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
Payclass Filters:GR
Eligibility Filter:Program Patients
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
TRAN-TRAN-FAMILY TRANSPORTATION 374 1597.000000 3305.6100 2.0699
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 10035 2262948.000 1152597.1000 0.5093
VISN-EIIF_NM-EI VISION SERVICES, IND NONMED 8 28.000000 1400.0000 50.0000
VISN-T1027SC-EI VISION SERVICES, INDIVIDUAL 1 10.000000 500.0000 50.0000
Subtotal (Total Children Is Unduplicated) 11024 2305782.514 3505623.8082 1.5204
-----------------------------------------------------------------------------------------------------------------------
Total 2350699.535078 5126186.4026 2.1807
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 17803
-----------------------------------------------------------------------------------------------------------------------
Center 01
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 1 50.000000 25.0000 0.0000
P 4741 207245.250000 247898.3400 247898.3400
D 33 12.250000 453.2500 0.0000
S 1 2.000000 250.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 2842 102236.750000 142302.1210 142302.1200
5558 11610.000000 138861.2800 0.0000
Other 346 10604.750000 18936.3600 0.0000
---------------------------------------------------------
Total 13522 331761.000000 548726.3510 390200.4600
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 779 36414.250000 49030.0300 49030.0300
2012 39901.750000 83642.0200 3275.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 2791 76316.000000 132672.0500 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 0 0.000000 0.0000 0.0000
P 2691 46936.250000 83323.2100 83323.2100
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
7322 88660.500000 195599.0700 0.0000
Other 4 4.000000 83.7400 0.0000
---------------------------------------------------------
Total 14669 138166.750000 361353.9400 165671.1300
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 2988 147371.250000 214300.7700 212607.5400
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 6 191.000000 661.6000 661.6000
T 0 0.000000 0.0000 0.0000
3938 3428.500000 107094.3900 0.0000
Other 11 29.000000 1860.0400 1554.5800
---------------------------------------------------------
Total 6943 151019.750000 323916.8000 214823.7200
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 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
3924 19623.500000 100971.2500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 7110 114931.000000 237779.2200 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 0 0.000000 0.0000 0.0000
P 3109 45244.750000 81526.3700 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
9165 60193.750000 227603.6900 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 12274 105438.500000 309130.0600 81526.3700
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 2899 153660.250000 218745.8100 218745.8100
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 0 0.000000 0.0000 0.0000
6606 9556.250000 156949.6000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 9505 163216.500000 375695.4100 218745.8100
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 14341 263949.500000 753885.7400 753885.7400
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
187 4647.750000 10909.9400 831.4600
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 14528 268597.250000 764795.6800 754717.2000
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 4729 183071.500000 369973.8500 369973.8500
D 14 14.000000 518.0000 18740.2500
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
6033 4452.250000 170510.2500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 10776 187537.750000 541002.1000 388714.1000
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 2086 112432.500000 147025.7100 146995.7100
D 17 15.750000 880.2900 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
3421 11496.000000 88755.6200 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 5524 123944.250000 236661.6200 146995.7100
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 388 18572.800212 19877.3900 19877.3900
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
4380 71266.223512 145422.0900 0.0000
Other 39 139.000000 5568.1400 0.0000
---------------------------------------------------------
Total 4807 89978.023724 170867.6200 19877.3900
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 2288 49906.250000 72554.4400 72688.8900
D 54 50.500000 2185.5000 0.0000
S 0 0.000000 0.0000 0.0000
H 1239 49511.512670 52206.1000 52206.1000
T 918 694.500000 20840.2500 20840.2500
3660 80528.571750 119144.8618 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 8159 180691.334420 266931.1518 145735.2400
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 2340 89808.570000 114233.7600 114233.7600
D 22 26.250000 1424.5000 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
5305 80580.265930 156062.9298 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 7667 170415.085930 271721.1898 114233.7600
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 3752 60071.705167 113203.3200 113203.3200
D 36 36.250000 1968.2500 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 1643 24069.441636 50590.2100 50590.2100
1674 1432.509701 37585.3800 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 7105 85609.906504 203347.1600 163793.5300
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 1 1.000000 37.0000 37.0000
D 14 11.000000 407.0000 0.0000
S 45 1289.500000 2778.1400 2778.1400
H 0 0.000000 0.0000 0.0000
T 3253 159058.184500 266752.2800 266752.2800
2862 2716.750000 111611.6300 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 6175 163076.434500 381586.0500 269567.4200