CMS/EIP Fiscal Report Statewide
Services beginning 04/01/2009 ending 06/30/2009 Date of Report:08/25/2009 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
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 2 2.50 92.50 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 56 143.75 5318.75 37.00
TCON-TCON-TRANSITION CONFERENCE 1 1.00 0.00 0.00
Subtotal (Total Children Is Unduplicated) 56 147.25 5411.25 36.75
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Screening, Eval, and Assessment,Class #02
EXIT-EXIT-TRANSITION ASSESSMENT 2 1.25 62.50 50.00
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 3 5.00 375.00 75.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 4 6.00 450.00 75.00
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 41 79.50 5962.50 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 33 44.50 3337.50 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 10 19.00 1425.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 3 4.00 222.00 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 2 8.00 600.00 75.00
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 16 16.00 2960.00 185.00
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 4 4.00 420.00 105.00
Subtotal (Total Children Is Unduplicated) 109 187.25 15814.50 84.46
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 1 3.00 1430.00 476.67
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 1 0.50 25.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 4 10.25 695.77 67.88
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 3 3.25 220.61 67.88
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 6 101.00 50.50 0.50
Subtotal (Total Children Is Unduplicated) 13 118.00 2421.88 20.52
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Total 452.50 23647.63 52.26
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Number of Children (Unduplicated) With at Least One Service 176
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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
20 20.00 3380.00 0.00
Other 0 0.00 0.00 0.00
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Total 20 20.00 3380.00 0.00
Center 06
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
6 26.25 3611.25 0.00
Other 0 0.00 0.00 0.00
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Total 6 26.25 3611.25 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 0 0.00 0.00 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
4 34.25 4211.25 0.00
Other 0 0.00 0.00 0.00
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Total 4 34.25 4211.25 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 0.00 0.00 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
236 296.75 19855.51 0.00
Other 0 0.00 0.00 0.00
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Total 236 296.75 19855.51 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 0.00 0.00 0.00
H 3 9.75 661.83 0.00
T 0 0.00 0.00 0.00
13 362.75 21558.80 0.00
Other 0 0.00 0.00 0.00
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Total 16 372.50 22220.63 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 0.00 0.00 0.00
H 0 9.75 661.83 0.00
T 0 0.00 0.00 0.00
43 400.75 22964.80 0.00
Other 0 0.00 0.00 0.00
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Total 43 410.50 23626.63 0.00
Center 57
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 9.75 661.83 0.00
T 0 0.00 0.00 0.00
2 442.75 22985.80 0.00
Other 0 0.00 0.00 0.00
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Total 2 452.50 23647.63 0.00