CMS/EIP Fiscal Report Statewide
Services beginning 07/01/2008 ending 09/30/2008 Date of Report:11/18/2008 Page: 1
Payclass Filters:LEA
Eligibility Filter:Program Patients
List order: No List
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Screening, Eval, and Assessment,Class #02
IPDEF-IPDEF_NM-F/U PSYCH & DEV EVAL BY NON-MED PROF 3 5.00 277.50 55.50
IPDEI-IPDEI_NM-INITIAL PSYCH & DEV EVAL BY NON-MED PR 10 17.00 943.50 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 16 26.00 1225.00 47.12
Subtotal (Total Children Is Unduplicated) 29 48.00 2446.00 50.96
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 1 1.00 50.00 50.00
CONIP-CONIP-CONSULT, ITDS, PHONE 1 0.25 6.25 25.00
ECE-ECE-EARLY CHILDHOOD EDUCATION 97 8352.00 75168.00 9.00
EIGF-EIGF_NM-EI GROUP SESSION BY NONMED PROF 55 1714.00 42850.00 25.00
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 58 1139.00 28475.00 25.00
EIIF-EIIF_NM-EI INDIVIDUAL SESSION BY NONMED PROF 62 262.00 9280.00 35.42
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 47 219.50 9675.00 44.08
OCCT-97530-OT SESSION BY LICENSED OT 64 199.25 13525.09 67.88
OCCT-97530HM-OT SESSION BY OT ASST 1 8.00 434.56 54.32
PHY-97110-PT SESSION BY LICENSED PT 68 193.50 13128.00 67.84
PHY-97110HM-PT SESSION BY PT ASST 1 4.00 217.28 54.32
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 95 263.00 17852.44 67.88
VISN-EIIF_NM-EI VISION SERVICES, IND NONMED 18 78.00 3900.00 50.00
Subtotal (Total Children Is Unduplicated) 343 12433.5 214561.62 17.26
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Total 12481.50 217007.62 17.39
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Number of Children (Unduplicated) With at Least One Service 372
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Center 01
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
41 78.00 3900.00 0.00
Other 0 0.00 0.00 0.00
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Total 41 78.00 3900.00 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
464 3441.00 107912.76 0.00
Other 0 0.00 0.00 0.00
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Total 464 3441.00 107912.76 0.00
Center 05
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
53 3537.50 112737.76 0.00
Other 0 0.00 0.00 0.00
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Total 53 3537.50 112737.76 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 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
13 3559.50 113958.76 0.00
Other 0 0.00 0.00 0.00
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Total 13 3559.50 113958.76 0.00
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 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
136 3849.00 123290.62 0.00
Other 0 0.00 0.00 0.00
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Total 136 3849.00 123290.62 0.00
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 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
361 12481.50 217007.62 0.00
Other 0 0.00 0.00 0.00
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Total 361 12481.50 217007.62 0.00