CMS/EIP Fiscal Report Statewide
Services beginning 04/01/2009 ending 06/30/2009 Date of Report:08/25/2009 Page: 1
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 132 79.75 2950.75 37.00
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 39 39.00 0.00 0.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 68 62.75 2321.75 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 408 1113.50 41199.50 37.00
Subtotal (Total Children Is Unduplicated) 411 1295.00 46472.00 35.89
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Screening, Eval, and Assessment,Class #02
EVAL-EVAL-DEVELOPMENTAL EVALUATION 7 5.50 275.00 50.00
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 2 2.50 187.50 75.00
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 1.00 75.00 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 4 5.00 277.50 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 11 14.50 1062.50 73.28
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 8 11.00 825.00 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 2 3.00 225.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 22 21.00 1165.50 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 29 25.50 1912.50 75.00
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 5 5.00 925.00 185.00
MED-99204-OUTPATIENT VISIT, NEW, 45 MINS 1 1.00 57.27 57.27
MED-99205-OUTPATIENT VISIT, NEW, 60 MINS 6 6.00 436.68 72.78
MED-99215-OUTPATIENT VISIT, EST, 40 MINS 3 3.00 150.45 50.15
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 2 2.00 97.00 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 1 1.00 48.50 48.50
SCREEN-T1023-INTERDISCIPLINARY SCREENING 10 11.00 550.00 50.00
SPCH-92506-SPEECH EVAL BY LICENSED SLP 1 1.00 48.50 48.50
Subtotal (Total Children Is Unduplicated) 68 120.00 8393.90 69.95
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 3 4.25 212.50 50.00
COIFP-COIFP-IFSP CONSULT, PRO, BY PHONE 1 0.25 6.25 25.00
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 1 1.00 50.00 50.00
CONIP-CONIP-CONSULT, ITDS, PHONE 1 0.50 12.50 25.00
CONPF-CONPF-CONSULT, PT, FACE TO FACE 1 0.25 12.50 50.00
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 2 1.75 87.50 50.00
EIIF-96154-HEALTH AND BEHAVIOR INTERVENTION 1 3.00 150.00 50.00
EIIF-EIIF_NM-EI INDIVIDUAL SESSION BY NONMED PROF 1 4.00 200.00 50.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 24 142.00 7100.00 50.00
INTR-INTR-INTERPRETER 3 5.00 250.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 3 19.00 1289.72 67.88
PHY-97110-PT SESSION BY LICENSED PT 5 23.50 1595.18 67.88
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 11 28.25 1917.61 67.88
TRAN-TRAN-FAMILY TRANSPORTATION 8 8.00 64.00 8.00
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 46 7198.00 3620.10 0.50
Subtotal (Total Children Is Unduplicated) 58 7438.75 16567.86 2.23
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Total 8853.75 71433.76 8.07
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Number of Children (Unduplicated) With at Least One Service 416
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Center 01
Flag Claims Units Chgs Paid
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R 20 18.00 1149.50 0.00
U 0 0.00 0.00 0.00
B 212 147.50 5971.25 0.00
P 215 2457.75 6347.01 6347.01
D 3 3.00 225.00 0.00
S 83 66.00 2442.00 0.00
H 0 0.00 0.00 0.00
T 31 1194.00 1064.52 1064.52
190 126.75 5117.25 0.00
Other 2 17.00 107.50 0.00
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Total 756 4030.00 22424.03 7411.53
Center 04
Flag Claims Units Chgs Paid
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R 1 18.75 1177.25 0.00
U 0 0.00 0.00 0.00
B 77 213.25 8459.50 0.00
P 135 3481.75 10927.21 10658.47
D 3 4.50 280.50 0.00
S 0 66.00 2442.00 0.00
H 8 24.00 1217.88 1217.88
T 0 1194.00 1064.52 1064.52
455 382.00 14637.50 0.00
Other 0 17.00 107.50 0.00
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Total 679 5401.25 40313.86 12940.87
Center 05
Flag Claims Units Chgs Paid
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R 1 19.75 1250.03 0.00
U 0 0.00 0.00 0.00
B 254 367.50 14414.02 0.00
P 0 3481.75 10927.21 10658.47
D 0 4.50 280.50 0.00
S 0 66.00 2442.00 0.00
H 0 24.00 1217.88 1217.88
T 0 1194.00 1064.52 1064.52
124 441.50 16633.08 0.00
Other 0 17.00 107.50 0.00
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Total 379 5616.00 48336.74 12940.87
Center 06
Flag Claims Units Chgs Paid
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R 0 19.75 1250.03 0.00
U 0 0.00 0.00 0.00
B 100 441.75 17161.27 37.00
P 141 4635.00 14347.72 14078.98
D 0 4.50 280.50 0.00
S 0 66.00 2442.00 0.00
H 0 24.00 1217.88 1217.88
T 0 1194.00 1064.52 1064.52
221 602.50 23447.03 92.50
Other 0 17.00 107.50 0.00
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Total 462 7004.50 61318.45 16490.88
Center 07
Flag Claims Units Chgs Paid
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R 0 19.75 1250.03 0.00
U 0 0.00 0.00 0.00
B 0 441.75 17161.27 37.00
P 6 4641.00 14569.72 14300.98
D 0 4.50 280.50 0.00
S 0 66.00 2442.00 0.00
H 0 24.00 1217.88 1217.88
T 0 1194.00 1064.52 1064.52
3 605.50 23558.03 92.50
Other 0 17.00 107.50 0.00
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Total 9 7013.50 61651.45 16712.88
Center 10
Flag Claims Units Chgs Paid
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R 0 19.75 1250.03 0.00
U 0 0.00 0.00 0.00
B 10 449.00 17466.52 37.00
P 4 4644.50 14813.22 14544.48
D 0 4.50 280.50 0.00
S 6 68.75 2543.75 0.00
H 0 24.00 1217.88 1217.88
T 0 1194.00 1064.52 1064.52
6 609.00 23650.53 92.50
Other 0 17.00 107.50 0.00
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Total 26 7030.50 62394.45 16956.38
Center 51
Flag Claims Units Chgs Paid
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R 0 19.75 1250.03 0.00
U 0 0.00 0.00 0.00
B 31 468.75 18197.27 37.00
P 40 5788.75 17855.80 17587.06
D 0 4.50 280.50 0.00
S 0 68.75 2543.75 0.00
H 0 24.00 1217.88 1217.88
T 0 1194.00 1064.52 1064.52
31 641.25 25462.18 92.50
Other 0 17.00 107.50 0.00
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Total 102 8226.75 67979.43 19998.96
Center 52
Flag Claims Units Chgs Paid
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R 0 19.75 1250.03 0.00
U 0 0.00 0.00 0.00
B 18 483.50 18874.52 37.00
P 0 5788.75 17855.80 17587.06
D 0 4.50 280.50 0.00
S 0 68.75 2543.75 0.00
H 0 24.00 1217.88 1217.88
T 0 1194.00 1064.52 1064.52
8 746.00 25640.43 92.50
Other 0 17.00 107.50 0.00
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Total 26 8346.25 68834.93 19998.96
Center 53
Flag Claims Units Chgs Paid
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R 0 19.75 1250.03 0.00
U 0 0.00 0.00 0.00
B 0 483.50 18874.52 37.00
P 16 5800.75 18377.80 18109.06
D 3 6.00 336.00 0.00
S 0 68.75 2543.75 0.00
H 1 114.00 1262.88 1262.88
T 6 1285.00 1146.52 1146.52
7 870.25 25846.68 92.50
Other 0 17.00 107.50 0.00
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Total 33 8665.00 69745.68 20647.96
Center 54
Flag Claims Units Chgs Paid
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R 1 20.25 1268.53 0.00
U 0 0.00 0.00 0.00
B 1 485.50 19024.52 37.00
P 38 5928.00 19339.88 19071.14
D 6 9.75 474.75 0.00
S 0 68.75 2543.75 0.00
H 0 114.00 1262.88 1262.88
T 0 1285.00 1146.52 1146.52
22 925.50 26265.43 92.50
Other 0 17.00 107.50 0.00
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Total 68 8853.75 71433.76 21610.04