CMS/EIP Fiscal Report Statewide
Services beginning 10/01/2008 ending 12/31/2008 Date of Report:02/17/2009 Page: 1
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 4 1.50 55.50 37.00
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 2 2.00 0.00 0.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 3 3.00 111.00 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 151 379.75 14031.50 36.95
Subtotal (Total Children Is Unduplicated) 151 386.25 14198.00 36.76
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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
EXIT-EXIT-TRANSITION ASSESSMENT 1 1.00 50.00 50.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 1.00 75.00 75.00
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 32 43.00 3066.00 71.30
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 5 6.00 242.50 40.42
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 6 10.00 723.50 72.35
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 16 33.00 1831.50 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 4 12.00 900.00 75.00
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 24 24.00 4440.00 185.00
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 7 7.00 735.00 105.00
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 2 2.00 97.00 48.50
SCREEN-T1023-INTERDISCIPLINARY SCREENING 1 1.00 50.00 50.00
Subtotal (Total Children Is Unduplicated) 93 142.00 12241.12 86.21
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 2 2.00 1100.00 550.00
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 6 8.00 400.00 50.00
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 4 3.25 162.50 50.00
CONIP-CONIP-CONSULT, ITDS, PHONE 7 5.00 125.00 25.00
CONOF-CONOF-CONSULT, OT, FACE TO FACE 1 2.00 100.00 50.00
CONPF-CONPF-CONSULT, PT, FACE TO FACE 1 2.00 100.00 50.00
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 16 23.00 1150.00 50.00
CONSP-CONSP-CONSULT, SLP, PHONE 2 0.50 12.50 25.00
ECE-ECE-EARLY CHILDHOOD EDUCATION 9 1372.00 12348.00 9.00
EIGF-EIGF_NM-EI GROUP SESSION BY NONMED PROF 60 2021.00 50525.00 25.00
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 5 68.00 1700.00 25.00
EIIF-EIIF_NM-EI INDIVIDUAL SESSION BY NONMED PROF 9 60.25 3012.50 50.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 10 80.00 4000.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 18 86.25 5803.80 67.29
PHY-97110-PT SESSION BY LICENSED PT 15 36.75 2494.59 67.88
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 31 62.25 4225.53 67.88
SPL-92508-GROUP SPL SESSION PER CHILD 1 1.00 13.20 13.20
TRAN-TRAN-FAMILY TRANSPORTATION 29 1020.00 93841.00 92.00
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 85 4064.00 4411.25 1.09
VISN-EIIF_NM-EI VISION SERVICES, IND NONMED 6 43.00 2150.00 50.00
Subtotal (Total Children Is Unduplicated) 241 8960.25 187674.87 20.95
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Total 9488.50 214113.99 22.57
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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
-------------------------------------------------
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
93 259.00 11250.00 0.00
Other 2 4.00 200.00 0.00
-------------------------------------------------
Total 95 263.00 11450.00 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
0 259.00 11250.00 0.00
Other 2 6.00 230.62 0.00
-------------------------------------------------
Total 2 265.00 11480.62 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
186 2311.00 66950.00 0.00
Other 0 6.00 230.62 0.00
-------------------------------------------------
Total 186 2317.00 67180.62 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 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
14 2353.75 67401.51 0.00
Other 0 6.00 230.62 0.00
-------------------------------------------------
Total 14 2359.75 67632.13 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 0.00 0.00 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
25 2399.75 70165.59 0.00
Other 0 6.00 230.62 0.00
-------------------------------------------------
Total 33 2418.00 71112.46 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 12.25 716.25 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
520 2831.25 87940.30 0.00
Other 0 6.00 230.62 0.00
-------------------------------------------------
Total 520 2849.50 88887.17 0.00
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 2 88.00 143.00 143.00
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
34 3058.50 92576.74 0.00
Other 0 6.00 230.62 0.00
-------------------------------------------------
Total 36 3164.75 93666.61 143.00
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 88.00 143.00 143.00
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
130 5069.25 99941.21 0.00
Other 0 6.00 230.62 0.00
-------------------------------------------------
Total 130 5175.50 101031.08 143.00
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 88.00 143.00 143.00
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
3 5165.25 100029.96 0.00
Other 0 6.00 230.62 0.00
-------------------------------------------------
Total 3 5271.50 101119.83 143.00
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 88.00 143.00 143.00
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
122 9229.75 210150.70 0.00
Other 37 158.50 3104.04 2873.42
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Total 159 9488.50 214113.99 3016.42