CMS/EIP Fiscal Report Statewide
Services beginning 10/01/2008 ending 12/31/2008 Date of Report:02/17/2009 Page: 1
Eligibility Filter:DEI Only
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 119 62.75 2321.75 37.00
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 59 59.00 0.00 0.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 80 74.75 2765.75 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 471 996.25 36842.75 36.98
TCON-TCON-TRANSITION CONFERENCE 1 1.00 0.00 0.00
Subtotal (Total Children Is Unduplicated) 475 1193.75 41930.25 35.12
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Screening, Eval, and Assessment,Class #02
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 3 3.00 26.49 8.83
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 3 3.00 32.40 10.80
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 3 3.00 65.37 21.79
EVAL-EVAL-DEVELOPMENTAL EVALUATION 16 14.50 725.00 50.00
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 5 6.00 450.00 75.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 5 8.00 600.00 75.00
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 2 2.50 187.50 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 6 6.00 412.50 68.75
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 4 5.50 305.25 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 14 18.50 1387.50 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 4 7.50 562.50 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 17 25.50 1912.50 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 15 18.00 999.00 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 28 31.00 2325.00 75.00
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 2 2.00 370.00 185.00
MED-99205-OUTPATIENT VISIT, NEW, 60 MINS 4 4.00 291.12 72.78
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 1 1.00 105.00 105.00
MED-99215-OUTPATIENT VISIT, EST, 40 MINS 7 7.00 351.05 50.15
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 1 1.00 48.50 48.50
SCREEN-T1023-INTERDISCIPLINARY SCREENING 2 2.00 100.00 50.00
Subtotal (Total Children Is Unduplicated) 78 169.00 11256.68 66.61
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EI Services,Class #03
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 1 1.00 50.00 50.00
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 1 1.00 50.00 50.00
EIIF-EIIF_NM-EI INDIVIDUAL SESSION BY NONMED PROF 1 2.00 100.00 50.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 16 68.50 3425.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 1 1.00 67.88 67.88
PHY-97110-PT SESSION BY LICENSED PT 3 12.00 814.56 67.88
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 7 46.50 3156.42 67.88
TRAN-TRAN-FAMILY TRANSPORTATION 9 9.00 65.50 7.28
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 31 4972.00 2634.85 0.53
Subtotal (Total Children Is Unduplicated) 44 5113.00 10364.21 2.03
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Total 6475.75 63551.14 9.81
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Number of Children (Unduplicated) With at Least One Service 478
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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 53 32.25 1193.25 0.00
P 26 582.00 666.80 666.80
D 17 14.00 556.00 0.00
S 75 45.75 1692.75 0.00
H 1 1.00 75.00 0.00
T 29 685.50 1116.30 1116.30
119 184.75 2291.19 0.00
Other 159 118.75 5660.00 0.00
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Total 479 1664.00 13251.29 1783.10
Center 04
Flag Claims Units Chgs Paid
-------------------------------------------------
R 1 0.75 27.75 0.00
U 0 0.00 0.00 0.00
B 111 118.00 4452.50 0.00
P 71 1030.75 3420.30 3473.13
D 0 14.00 556.00 0.00
S 0 45.75 1692.75 0.00
H 2 9.00 475.00 400.00
T 0 685.50 1116.30 1116.30
384 402.50 9799.94 0.00
Other 0 118.75 5660.00 0.00
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Total 569 2425.00 27200.54 4989.43
Center 05
Flag Claims Units Chgs Paid
-------------------------------------------------
R 7 7.75 450.83 0.00
U 0 0.00 0.00 0.00
B 295 277.00 10335.50 0.00
P 6 1202.25 3827.80 3880.63
D 0 14.00 556.00 0.00
S 0 45.75 1692.75 0.00
H 0 9.00 475.00 400.00
T 0 685.50 1116.30 1116.30
126 478.00 12657.73 0.00
Other 0 118.75 5660.00 0.00
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Total 434 2838.00 36771.91 5396.93
Center 06
Flag Claims Units Chgs Paid
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R 0 7.75 450.83 0.00
U 0 0.00 0.00 0.00
B 238 414.50 15423.00 0.00
P 45 1401.25 4622.30 4675.13
D 0 14.00 556.00 0.00
S 0 45.75 1692.75 0.00
H 0 9.00 475.00 400.00
T 0 685.50 1116.30 1116.30
177 1009.75 18213.68 0.00
Other 0 118.75 5660.00 0.00
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Total 460 3706.25 48209.86 6191.43
Center 07
Flag Claims Units Chgs Paid
-------------------------------------------------
R 0 7.75 450.83 0.00
U 0 0.00 0.00 0.00
B 0 414.50 15423.00 0.00
P 1 1401.50 4631.55 4684.38
D 0 14.00 556.00 0.00
S 0 45.75 1692.75 0.00
H 0 9.00 475.00 400.00
T 0 685.50 1116.30 1116.30
0 1009.75 18213.68 0.00
Other 0 118.75 5660.00 0.00
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Total 1 3706.50 48219.11 6200.68
Center 10
Flag Claims Units Chgs Paid
-------------------------------------------------
R 0 7.75 450.83 0.00
U 0 0.00 0.00 0.00
B 63 463.50 17282.25 0.00
P 5 1408.50 5156.55 5209.38
D 0 14.00 556.00 0.00
S 0 45.75 1692.75 0.00
H 0 9.00 475.00 400.00
T 0 685.50 1116.30 1116.30
28 1037.25 19251.18 0.00
Other 0 118.75 5660.00 0.00
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Total 96 3790.00 51640.86 6725.68
Center 51
Flag Claims Units Chgs Paid
-------------------------------------------------
R 0 7.75 450.83 0.00
U 0 0.00 0.00 0.00
B 36 491.50 18318.25 0.00
P 34 3370.00 8286.75 8339.58
D 0 14.00 556.00 0.00
S 0 45.75 1692.75 0.00
H 0 9.00 475.00 400.00
T 0 685.50 1116.30 1116.30
48 1072.00 20927.11 0.00
Other 0 118.75 5660.00 0.00
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Total 118 5814.25 57482.99 9855.88
Center 52
Flag Claims Units Chgs Paid
-------------------------------------------------
R 0 7.75 450.83 0.00
U 0 0.00 0.00 0.00
B 3 492.25 18346.00 0.00
P 9 3377.00 8621.25 8674.08
D 0 14.00 556.00 0.00
S 0 45.75 1692.75 0.00
H 0 9.00 475.00 400.00
T 0 685.50 1116.30 1116.30
7 1104.25 20988.36 0.00
Other 0 118.75 5660.00 0.00
-------------------------------------------------
Total 19 5854.25 57906.49 10190.38
Center 53
Flag Claims Units Chgs Paid
-------------------------------------------------
R 4 10.00 534.08 0.00
U 0 0.00 0.00 0.00
B 0 492.25 18346.00 0.00
P 19 3392.50 9416.75 9469.58
D 8 20.00 835.00 0.00
S 0 45.75 1692.75 0.00
H 13 47.25 758.25 683.25
T 4 688.50 1227.30 1227.30
11 1179.25 21688.36 0.00
Other 0 118.75 5660.00 0.00
-------------------------------------------------
Total 59 5994.25 60158.49 11380.13
Center 54
Flag Claims Units Chgs Paid
-------------------------------------------------
R 0 10.00 534.08 0.00
U 0 0.00 0.00 0.00
B 29 508.00 18928.75 0.00
P 54 3664.25 10707.40 10760.23
D 0 20.00 835.00 0.00
S 0 45.75 1692.75 0.00
H 0 47.25 758.25 683.25
T 0 688.50 1227.30 1227.30
31 1355.25 22502.61 0.00
Other 0 118.75 5660.00 0.00
-------------------------------------------------
Total 114 6457.75 62846.14 12670.78
Center 55
Flag Claims Units Chgs Paid
-------------------------------------------------
R 0 10.00 534.08 0.00
U 0 0.00 0.00 0.00
B 0 508.00 18928.75 0.00
P 0 3664.25 10707.40 10760.23
D 0 20.00 835.00 0.00
S 0 45.75 1692.75 0.00
H 0 47.25 758.25 683.25
T 0 688.50 1227.30 1227.30
2 1356.75 22558.11 0.00
Other 0 118.75 5660.00 0.00
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Total 2 6459.25 62901.64 12670.78
Center 57
Flag Claims Units Chgs Paid
-------------------------------------------------
R 0 10.00 534.08 0.00
U 0 0.00 0.00 0.00
B 1 508.25 18938.00 0.00
P 4 3670.50 10938.65 10991.48
D 0 20.00 835.00 0.00
S 1 46.00 1702.00 0.00
H 0 47.25 758.25 683.25
T 0 688.50 1227.30 1227.30
12 1366.50 22957.86 0.00
Other 0 118.75 5660.00 0.00
-------------------------------------------------
Total 18 6475.75 63551.14 12902.03