CMS/EIP Fiscal Report Statewide
Services beginning 10/01/2008 ending 12/31/2008 Date of Report:02/16/2009 Page: 1
Payclass Filters:GR
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 143 269.00 9953.00 37.00
TCON-TCON-TRANSITION CONFERENCE 1 1.00 0.00 0.00
Subtotal (Total Children Is Unduplicated) 288 466.50 15040.50 32.24
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Screening, Eval, and Assessment,Class #02
EVAL-EVAL-DEVELOPMENTAL EVALUATION 11 9.50 475.00 50.00
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 3 4.50 337.50 75.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 2.00 150.00 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 1 1.00 75.00 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 1 2.00 111.00 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 3 4.00 300.00 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 7 8.50 637.50 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 3 4.50 249.75 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 2 2.00 150.00 75.00
Subtotal (Total Children Is Unduplicated) 27 38.00 2485.75 65.41
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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 6 42.50 2125.00 50.00
PHY-97110-PT SESSION BY LICENSED PT 1 6.50 441.22 67.88
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 3 21.00 1425.48 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) 40 5055.00 6892.05 1.36
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Total 5559.50 24418.30 4.39
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Number of Children (Unduplicated) With at Least One Service 302
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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 26 582.00 666.80 666.80
D 1 1.00 75.00 0.00
S 23 10.00 370.00 0.00
H 0 0.00 0.00 0.00
T 29 685.50 1116.30 1116.30
96 165.50 1318.10 0.00
Other 2 3.00 1.50 0.00
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Total 177 1447.00 3547.70 1783.10
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 8 987.00 1364.30 1364.30
D 0 1.00 75.00 0.00
S 0 10.00 370.00 0.00
H 0 0.00 0.00 0.00
T 0 685.50 1116.30 1116.30
382 382.00 8780.60 0.00
Other 0 3.00 1.50 0.00
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Total 390 2068.50 11707.70 2480.60
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 6 1158.50 1771.80 1771.80
D 0 1.00 75.00 0.00
S 0 10.00 370.00 0.00
H 0 0.00 0.00 0.00
T 0 685.50 1116.30 1116.30
100 434.00 10149.60 0.00
Other 0 3.00 1.50 0.00
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Total 106 2292.00 13484.20 2888.10
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 45 1357.50 2566.30 2566.30
D 0 1.00 75.00 0.00
S 0 10.00 370.00 0.00
H 0 0.00 0.00 0.00
T 0 685.50 1116.30 1116.30
131 918.75 13076.85 0.00
Other 0 3.00 1.50 0.00
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Total 176 2975.75 17205.95 3682.60
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 1 1357.75 2575.55 2575.55
D 0 1.00 75.00 0.00
S 0 10.00 370.00 0.00
H 0 0.00 0.00 0.00
T 0 685.50 1116.30 1116.30
0 918.75 13076.85 0.00
Other 0 3.00 1.50 0.00
-------------------------------------------------
Total 1 2976.00 17215.20 3691.85
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 0.00 0.00 0.00
P 0 1357.75 2575.55 2575.55
D 0 1.00 75.00 0.00
S 0 10.00 370.00 0.00
H 0 0.00 0.00 0.00
T 0 685.50 1116.30 1116.30
28 946.25 14114.35 0.00
Other 0 3.00 1.50 0.00
-------------------------------------------------
Total 28 3003.50 18252.70 3691.85
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 34 3319.25 5705.75 5705.75
D 0 1.00 75.00 0.00
S 0 10.00 370.00 0.00
H 0 0.00 0.00 0.00
T 0 685.50 1116.30 1116.30
39 966.00 14845.10 0.00
Other 0 3.00 1.50 0.00
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Total 73 4984.75 22113.65 6822.05
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 3319.25 5705.75 5705.75
D 0 1.00 75.00 0.00
S 0 10.00 370.00 0.00
H 0 0.00 0.00 0.00
T 0 685.50 1116.30 1116.30
7 998.25 14906.35 0.00
Other 0 3.00 1.50 0.00
-------------------------------------------------
Total 7 5017.00 22174.90 6822.05
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 3319.25 5705.75 5705.75
D 0 1.00 75.00 0.00
S 0 10.00 370.00 0.00
H 13 38.25 283.25 283.25
T 4 688.50 1227.30 1227.30
11 1073.25 15606.35 0.00
Other 0 3.00 1.50 0.00
-------------------------------------------------
Total 28 5133.25 23269.15 7216.30
Center 54
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 8 3565.75 6071.40 6071.40
D 0 1.00 75.00 0.00
S 0 10.00 370.00 0.00
H 0 38.25 283.25 283.25
T 0 688.50 1227.30 1227.30
25 1243.75 16065.10 0.00
Other 0 3.00 1.50 0.00
-------------------------------------------------
Total 33 5550.25 24093.55 7581.95
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 0.00 0.00 0.00
P 0 3565.75 6071.40 6071.40
D 0 1.00 75.00 0.00
S 0 10.00 370.00 0.00
H 0 38.25 283.25 283.25
T 0 688.50 1227.30 1227.30
2 1245.25 16120.60 0.00
Other 0 3.00 1.50 0.00
-------------------------------------------------
Total 2 5551.75 24149.05 7581.95
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 3565.75 6071.40 6071.40
D 0 1.00 75.00 0.00
S 0 10.00 370.00 0.00
H 0 38.25 283.25 283.25
T 0 688.50 1227.30 1227.30
10 1253.00 16389.85 0.00
Other 0 3.00 1.50 0.00
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Total 10 5559.50 24418.30 7581.95