CMS/EIP Fiscal Report Statewide
Services beginning 01/01/2009 ending 03/31/2009 Date of Report:05/18/2009 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 10 5.75 212.75 37.00
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 5 5.00 0.00 0.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 2 3.50 129.50 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 185 516.50 19110.50 37.00
TCON-TCON-TRANSITION CONFERENCE 1 1.00 0.00 0.00
Subtotal (Total Children Is Unduplicated) 188 531.75 19452.75 36.58
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 1 2.00 150.00 75.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 3 3.00 225.00 75.00
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 28 52.50 3937.50 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 17 27.00 2025.00 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 5 9.50 712.50 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 2 4.00 222.00 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 3 5.50 412.50 75.00
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 18 18.00 3330.00 185.00
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
Subtotal (Total Children Is Unduplicated) 78 129.50 12024.50 92.85
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EI Services,Class #03
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 1 1.00 50.00 50.00
CONOF-CONOF-CONSULT, OT, FACE TO FACE 1 0.25 12.50 50.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 1 0.25 12.50 50.00
OCCT-97530-OT SESSION BY LICENSED OT 1 1.50 101.82 67.88
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 2 4.00 271.52 67.88
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 7 210.00 105.00 0.50
Subtotal (Total Children Is Unduplicated) 11 217.00 553.34 2.55
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Total 878.25 32030.59 36.47
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Number of Children (Unduplicated) With at Least One Service 265
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Center 04
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
26 26.00 4340.00 0.00
Other 0 0.00 0.00 0.00
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Total 26 26.00 4340.00 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
45 54.00 5228.00 0.00
Other 0 0.00 0.00 0.00
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Total 45 54.00 5228.00 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 1 0.50 18.50 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
22 77.25 6371.25 0.00
Other 0 0.00 0.00 0.00
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Total 23 77.75 6389.75 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 0.50 18.50 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
642 656.00 31323.25 0.00
Other 0 0.00 0.00 0.00
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Total 642 656.50 31341.75 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 0.50 18.50 0.00
H 3 5.50 373.34 0.00
T 0 0.00 0.00 0.00
9 867.25 31490.75 0.00
Other 0 0.00 0.00 0.00
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Total 12 873.25 31882.59 0.00
Center 53
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 0.50 18.50 0.00
H 0 5.50 373.34 0.00
T 0 0.00 0.00 0.00
3 872.25 31638.75 0.00
Other 0 0.00 0.00 0.00
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Total 3 878.25 32030.59 0.00