CMS/EIP Fiscal Report Statewide
Services beginning 07/01/2008 ending 09/30/2008 Date of Report:11/18/2008 Page: 1
Payclass Filters:OTHER
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 5 1.50 55.50 37.00
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 5 5.00 0.00 0.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 8 6.00 222.00 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 118 255.50 9453.50 37.00
Subtotal (Total Children Is Unduplicated) 126 268.00 9731.00 36.31
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Screening, Eval, and Assessment,Class #02
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 1 1.00 8.83 8.83
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 1 1.00 21.79 21.79
IPDEI-IPDEI_NM-INITIAL PSYCH & DEV EVAL BY NON-MED PR 2 2.00 97.00 48.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 16 17.50 930.50 53.17
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 11 17.50 1233.00 70.46
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 6 6.00 291.00 48.50
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 29 56.50 3135.75 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 2 3.00 225.00 75.00
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 30 30.00 5550.00 185.00
MED-99204-OUTPATIENT VISIT, NEW, 45 MINS 1 1.00 275.00 275.00
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 1 1.00 105.00 105.00
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 6 6.00 291.00 48.50
Subtotal (Total Children Is Unduplicated) 98 142.50 12163.87 85.36
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EI Services,Class #03
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 2 0.75 37.50 50.00
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 11 9.25 462.50 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 25 60.00 4072.80 67.88
TRAN-TRAN-FAMILY TRANSPORTATION 28 1200.00 120000.00 100.00
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 51 2357.46 1156.23 0.49
VISN-EIIF_NM-EI VISION SERVICES, IND NONMED 8 80.00 4000.00 50.00
Subtotal (Total Children Is Unduplicated) 266 7161.46 210553.52 29.40
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Total 7571.96 232448.39 30.70
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Number of Children (Unduplicated) With at Least One Service 484
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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
-------------------------------------------------
Total 59 163.50 9140.52 0.00
Center 03
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
0 163.50 9140.52 0.00
Other 2 2.00 30.62 0.00
-------------------------------------------------
Total 2 165.50 9171.14 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 3 2.25 159.25 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
240 2602.50 76270.52 0.00
Other 0 2.00 30.62 0.00
-------------------------------------------------
Total 243 2606.75 76460.39 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 2.25 159.25 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
79 2664.25 78135.97 0.00
Other 0 2.00 30.62 0.00
-------------------------------------------------
Total 79 2668.50 78325.84 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 2.25 159.25 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
36 2961.25 82315.67 0.00
Other 0 2.00 30.62 0.00
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Total 36 2965.50 82505.54 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 2.25 159.25 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
300 3230.25 93801.55 0.00
Other 0 2.00 30.62 0.00
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Total 305 3253.50 95120.22 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 2.25 159.25 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
27 3318.50 96697.40 0.00
Other 0 2.00 30.62 0.00
-------------------------------------------------
Total 30 3458.75 98290.45 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 2.25 159.25 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
91 4694.21 99975.70 0.00
Other 0 2.00 30.62 0.00
-------------------------------------------------
Total 91 4834.46 101568.75 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 2.25 159.25 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 4816.21 101651.84 0.00
Other 0 2.00 30.62 0.00
-------------------------------------------------
Total 34 4956.46 103244.89 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 2.25 159.25 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 7002.21 229487.60 0.00
Other 12 371.50 1368.36 1337.74
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Total 82 7571.96 232448.39 2770.92