CMS/EIP Fiscal Report Statewide
Services beginning 07/01/2008 ending 09/30/2008 Date of Report:11/18/2008 Page: 1
Agency Filter:EXT
Payclass Filters:OTHER
Eligibility Filter:Part C (excluding not eligible)
List order: No List
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Screening, Eval, and Assessment,Class #02
IPDEI-IPDEI_NM-INITIAL PSYCH & DEV EVAL BY NON-MED PR 1 1.00 48.50 48.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 10 10.00 485.00 48.50
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 3 3.00 145.50 48.50
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 5 5.00 242.50 48.50
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 6 6.00 291.00 48.50
Subtotal (Total Children Is Unduplicated) 20 25.00 1212.50 48.50
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EI Services,Class #03
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 1 0.50 25.00 50.00
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 10 8.25 412.50 50.00
ECE-ECE-EARLY CHILDHOOD EDUCATION 7 848.00 7632.00 9.00
EIGF-EIGF_NM-EI GROUP SESSION BY NONMED PROF 53 1518.00 37950.00 25.00
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 39 848.00 21200.00 25.00
EIIF-EIIF_NM-EI INDIVIDUAL SESSION BY NONMED PROF 10 63.25 3162.50 50.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 26 61.00 3050.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 13 40.25 2732.17 67.88
OCCT-97530HM-OT SESSION BY OT ASST 1 1.00 54.32 54.32
PHY-97110-PT SESSION BY LICENSED PT 23 73.00 4955.24 67.88
PHY-97110HM-PT SESSION BY PT ASST 2 1.50 88.26 58.84
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 24 57.00 3869.16 67.88
TRAN-TRAN-FAMILY TRANSPORTATION 28 1200.00 120000.00 100.00
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 44 2112.00 1033.50 0.49
VISN-EIIF_NM-EI VISION SERVICES, IND NONMED 8 80.00 4000.00 50.00
Subtotal (Total Children Is Unduplicated) 258 6911.75 210164.65 30.41
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Total 6936.75 211377.15 30.47
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Number of Children (Unduplicated) With at Least One Service 273
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Center 01
Flag Claims Units Chgs Paid
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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 0 0.00 0.00 0.00
59 163.50 9140.52 0.00
Other 0 0.00 0.00 0.00
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Total 59 163.50 9140.52 0.00
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 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 0 0.00 0.00 0.00
208 2570.50 70340.52 0.00
Other 0 0.00 0.00 0.00
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Total 208 2570.50 70340.52 0.00
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 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 0 0.00 0.00 0.00
7 2586.00 70642.72 0.00
Other 0 0.00 0.00 0.00
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Total 7 2586.00 70642.72 0.00
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 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 0 0.00 0.00 0.00
6 2826.25 71674.17 0.00
Other 0 0.00 0.00 0.00
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Total 6 2826.25 71674.17 0.00
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 5 19.00 1128.80 1128.80
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
8 2854.25 73539.05 0.00
Other 0 0.00 0.00 0.00
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Total 13 2873.25 74667.85 1128.80
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 3 136.00 1403.18 1403.18
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
21 2895.50 76209.26 0.00
Other 0 0.00 0.00 0.00
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Total 24 3031.50 77612.44 1403.18
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 0 136.00 1403.18 1403.18
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
76 4063.25 79094.33 0.00
Other 0 0.00 0.00 0.00
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Total 76 4199.25 80497.51 1403.18
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 0 136.00 1403.18 1403.18
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
34 4185.25 80770.47 0.00
Other 0 0.00 0.00 0.00
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Total 34 4321.25 82173.65 1403.18
Center 57
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 0 136.00 1403.18 1403.18
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 1 60.00 30.00 30.00
69 6371.25 208606.23 0.00
Other 12 369.50 1337.74 1337.74
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Total 82 6936.75 211377.15 2770.92