CMS/EIP Fiscal Report Statewide
Services beginning 01/01/2008 ending 12/31/2008 Date of Report:02/17/2009 Page: 1
Agency Filter:EIP DEI DEIP
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
Service Coordination,Class #01
CASE-CASE-NON-TCM CASE MANAGEMENT 6 2.00 74.00 37.00
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 10 10.00 0.00 0.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 11 8.75 323.75 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 262 818.75 30274.50 36.98
Subtotal (Total Children Is Unduplicated) 265 839.50 30672.25 36.54
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Screening, Eval, and Assessment,Class #02
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 5 5.00 43.25 8.65
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 3 3.00 31.98 10.66
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 5 5.00 104.16 20.83
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 1 1.00 28.28 28.28
EVAL-EVAL-DEVELOPMENTAL EVALUATION 6 6.50 333.25 51.27
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 1 1.00 75.00 75.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 1.00 75.00 75.00
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 1.00 75.00 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 1 0.50 27.75 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 31 42.50 3187.50 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 5 9.50 712.50 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 4 7.00 525.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 45 89.50 4967.25 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 7 17.50 1312.50 75.00
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 48 48.00 8880.00 185.00
MED-99204-OUTPATIENT VISIT, NEW, 45 MINS 1 1.00 275.00 275.00
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 7 7.00 735.00 105.00
MED-99214-OUTPATIENT VISIT, EST, 25 MINS 1 1.00 160.00 160.00
SCREEN-T1023-INTERDISCIPLINARY SCREENING 1 1.00 50.00 50.00
SPCH-92506-SPEECH EVAL BY LICENSED SLP 1 1.00 48.50 48.50
Subtotal (Total Children Is Unduplicated) 158 249.00 21646.92 86.94
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 2 2.00 1100.00 550.00
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 4 1.50 75.00 50.00
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 1 1.00 50.00 50.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 3 15.50 775.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 2 1.75 118.79 67.88
PHY-97110-PT SESSION BY LICENSED PT 1 1.00 67.88 67.88
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 7 23.50 1595.18 67.88
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 27 1067.46 533.73 0.50
Subtotal (Total Children Is Unduplicated) 40 1113.71 4315.58 3.88
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Total 2202.21 56634.75 25.72
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Number of Children (Unduplicated) With at Least One Service 455
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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 0.00 0.00 0.00
Other 14 14.00 207.67 0.00
-------------------------------------------------
Total 14 14.00 207.67 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 1 1.00 75.00 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
57 57.00 10050.00 0.00
Other 0 14.00 207.67 0.00
-------------------------------------------------
Total 58 72.00 10332.67 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 1.00 75.00 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
144 159.00 13528.00 0.00
Other 0 14.00 207.67 0.00
-------------------------------------------------
Total 144 174.00 13810.67 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 1.00 75.00 0.00
P 0 0.00 0.00 0.00
D 0 0.00 0.00 0.00
S 8 12.25 716.25 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
51 253.50 18969.00 0.00
Other 0 14.00 207.67 0.00
-------------------------------------------------
Total 59 280.75 19967.92 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 1.00 75.00 0.00
P 7 20.00 1089.40 1089.40
D 0 0.00 0.00 0.00
S 0 12.25 716.25 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
886 963.75 46703.19 0.00
Other 0 14.00 207.67 0.00
-------------------------------------------------
Total 893 1011.00 48791.51 1089.40
Center 10
Flag Claims Units Chgs Paid
-------------------------------------------------
R 0 0.00 0.00 0.00
U 0 0.00 0.00 0.00
B 0 1.00 75.00 0.00
P 0 20.00 1089.40 1089.40
D 0 0.00 0.00 0.00
S 0 12.25 716.25 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
1 964.00 46712.44 0.00
Other 0 14.00 207.67 0.00
-------------------------------------------------
Total 1 1011.25 48800.76 1089.40
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 1.00 75.00 0.00
P 0 20.00 1089.40 1089.40
D 0 0.00 0.00 0.00
S 0 12.25 716.25 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
12 1051.00 47160.22 0.00
Other 0 14.00 207.67 0.00
-------------------------------------------------
Total 12 1098.25 49248.54 1089.40
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 1.00 75.00 0.00
P 0 20.00 1089.40 1089.40
D 0 0.00 0.00 0.00
S 0 12.25 716.25 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
74 2087.46 52048.93 0.00
Other 0 14.00 207.67 0.00
-------------------------------------------------
Total 74 2134.71 54137.25 1089.40
Center 55
Flag Claims Units Chgs Paid
-------------------------------------------------
R 0 0.00 0.00 0.00
U 0 0.00 0.00 0.00
B 0 1.00 75.00 0.00
P 0 20.00 1089.40 1089.40
D 0 0.00 0.00 0.00
S 0 12.25 716.25 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
72 2154.96 54546.43 0.00
Other 0 14.00 207.67 0.00
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Total 72 2202.21 56634.75 1089.40