CMS/EIP Fiscal Report Statewide
Services beginning 10/01/2008 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 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
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 25 35.50 2662.50 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 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
SCREEN-T1023-INTERDISCIPLINARY SCREENING 1 1.00 50.00 50.00
Subtotal (Total Children Is Unduplicated) 77 122.50 11249.62 91.83
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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 1 0.25 12.50 50.00
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 6 15.00 1018.20 67.88
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 16 584.00 292.00 0.50
Subtotal (Total Children Is Unduplicated) 22 601.25 2422.70 4.03
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Total 1110.00 27870.32 25.11
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Number of Children (Unduplicated) With at Least One Service 246
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Center 03
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
0 0.00 0.00 0.00
Other 2 2.00 30.62 0.00
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Total 2 2.00 30.62 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
31 31.00 5175.00 0.00
Other 0 2.00 30.62 0.00
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Total 31 33.00 5205.62 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
8 38.75 5424.75 0.00
Other 0 2.00 30.62 0.00
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Total 8 40.75 5455.37 0.00
Center 07
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 8 12.25 716.25 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
20 75.00 7527.00 0.00
Other 0 2.00 30.62 0.00
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Total 28 89.25 8273.87 0.00
Center 09
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 12.25 716.25 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
506 471.50 22900.99 0.00
Other 0 2.00 30.62 0.00
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Total 506 485.75 23647.86 0.00
Center 51
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 12.25 716.25 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
6 511.50 23123.13 0.00
Other 0 2.00 30.62 0.00
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Total 6 525.75 23870.00 0.00
Center 52
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 12.25 716.25 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
45 1095.75 27123.45 0.00
Other 0 2.00 30.62 0.00
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Total 45 1110.00 27870.32 0.00