CMS/EIP Fiscal Report Statewide
Services beginning 01/01/2009 ending 03/31/2009 Date of Report:05/18/2009 Page: 1
Payclass Filters:OTHER
Eligibility Filter:Program Patients
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 12 6.25 231.25 37.00
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 5 5.00 0.00 0.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 3 3.75 138.75 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 204 542.25 20063.25 37.00
TCON-TCON-TRANSITION CONFERENCE 1 1.00 0.00 0.00
Subtotal (Total Children Is Unduplicated) 207 558.25 20433.25 36.60
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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 5 5.50 412.50 75.00
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 58 94.00 6986.00 74.32
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 33 50.00 3686.00 73.72
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 11 18.00 1169.00 64.94
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 4 7.50 562.50 75.00
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 21 21.00 3885.00 185.00
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
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 3 3.00 145.50 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 1 1.00 48.50 48.50
SPCH-92506-SPEECH EVAL BY LICENSED SLP 1 1.00 48.50 48.50
Subtotal (Total Children Is Unduplicated) 137 215.00 18325.50 85.23
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EI Services,Class #03
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 9 7.50 375.00 50.00
CONIP-CONIP-CONSULT, ITDS, PHONE 2 2.00 50.00 25.00
CONOF-CONOF-CONSULT, OT, FACE TO FACE 1 0.25 12.50 50.00
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 18 30.00 1500.00 50.00
CONSP-CONSP-CONSULT, SLP, PHONE 1 1.00 25.00 25.00
ECE-ECE-EARLY CHILDHOOD EDUCATION 8 288.00 3012.00 10.46
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 6 87.00 2175.00 25.00
EIIF-EIIF_NM-EI INDIVIDUAL SESSION BY NONMED PROF 18 78.00 3900.00 50.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 8 89.25 4462.50 50.00
HERN-EIIF_NM-EI HEARING SERVICES AFTER SHINE NONMED 8 20.50 1025.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 21 84.75 5752.83 67.88
OCCT-97530HM-OT SESSION BY OT ASST 1 4.00 217.28 54.32
PHY-97110-PT SESSION BY LICENSED PT 9 27.75 1883.67 67.88
PHY-97110HM-PT SESSION BY PT ASST 1 0.50 27.16 54.32
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 32 69.00 4891.66 70.89
SPL-92508-GROUP SPL SESSION PER CHILD 5 100.00 1320.00 13.20
TRAN-TRAN-FAMILY TRANSPORTATION 30 1134.00 16290.00 14.37
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 72 2577.00 1595.50 0.62
VISN-EIIF_NM-EI VISION SERVICES, IND NONMED 16 115.25 5762.50 50.00
Subtotal (Total Children Is Unduplicated) 185 4715.75 54277.60 11.51
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Total 5489.00 93036.35 16.95
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Number of Children (Unduplicated) With at Least One Service 507
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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
122 349.75 15312.50 0.00
Other 0 0.00 0.00 0.00
-------------------------------------------------
Total 122 349.75 15312.50 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
1 351.75 15462.50 0.00
Other 0 0.00 0.00 0.00
-------------------------------------------------
Total 1 351.75 15462.50 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
29 380.75 20357.50 0.00
Other 0 0.00 0.00 0.00
-------------------------------------------------
Total 29 380.75 20357.50 0.00
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 13 11.25 662.50 662.50
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
0 380.75 20357.50 0.00
Other 0 0.00 0.00 0.00
-------------------------------------------------
Total 13 392.00 21020.00 662.50
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 11.25 662.50 662.50
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
115 517.00 22901.63 0.00
Other 0 0.00 0.00 0.00
-------------------------------------------------
Total 115 528.25 23564.13 662.50
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 2 7.25 362.50 362.50
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
25 654.25 24121.92 0.00
Other 0 0.00 0.00 0.00
-------------------------------------------------
Total 28 662.00 24502.92 362.50
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 1 12.25 701.90 701.90
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
718 1390.25 59619.97 0.00
Other 0 0.00 0.00 0.00
-------------------------------------------------
Total 719 1403.00 60340.37 701.90
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 0 12.25 701.90 701.90
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
34 1449.75 63179.91 0.00
Other 0 0.00 0.00 0.00
-------------------------------------------------
Total 34 1462.50 63900.31 701.90
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 12.25 701.90 701.90
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
102 2875.75 67674.73 0.00
Other 0 0.00 0.00 0.00
-------------------------------------------------
Total 105 2894.00 68768.47 701.90
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 12.25 701.90 701.90
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 2880.75 67822.73 0.00
Other 0 0.00 0.00 0.00
-------------------------------------------------
Total 3 2899.00 68916.47 701.90
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 12.25 701.90 701.90
D 0 0.00 0.00 0.00
S 3 122.50 178.50 160.00
H 0 5.50 373.34 0.00
T 0 0.00 0.00 0.00
84 5089.75 88356.65 0.00
Other 40 259.00 3425.96 3527.78
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Total 127 5489.00 93036.35 4389.68