CMS/EIP Fiscal Report Statewide
Services beginning 04/01/2009 ending 06/30/2009 Date of Report:08/25/2009 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
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 2 2.50 92.50 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 66 162.75 6021.75 37.00
TCON-TCON-TRANSITION CONFERENCE 1 1.00 0.00 0.00
Subtotal (Total Children Is Unduplicated) 66 166.25 6114.25 36.78
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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 5 9.00 675.00 75.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 4 6.00 450.00 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 1 3.00 225.00 75.00
IPDEI-IPDEI_NM-INITIAL PSYCH & DEV EVAL BY NON-MED PR 7 10.00 584.25 58.43
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 61 114.50 8587.50 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 48 57.50 4312.50 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 13 22.50 1687.50 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 6 9.50 527.25 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 4 11.50 862.50 75.00
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 22 22.00 4070.00 185.00
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 4 4.00 420.00 105.00
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
SPCH-92506-SPEECH EVAL BY LICENSED SLP 5 5.00 242.50 48.50
VISD-VISD-VISION EVALUATION DIAGNOSTIC 1 1.00 100.00 100.00
VISF-VISF-VISION EVALUATION FUNCTIONAL 3 3.25 162.50 50.00
Subtotal (Total Children Is Unduplicated) 177 283.00 23114.50 81.68
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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 7 4.50 225.00 50.00
CONIP-CONIP-CONSULT, ITDS, PHONE 1 2.00 50.00 25.00
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 14 8.00 400.00 50.00
CONSP-CONSP-CONSULT, SLP, PHONE 1 1.50 37.50 25.00
ECE-ECE-EARLY CHILDHOOD EDUCATION 9 460.00 4140.00 9.00
EIGF-EIGF_NM-EI GROUP SESSION BY NONMED PROF 31 350.00 8750.00 25.00
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 50 415.00 10375.00 25.00
EIIF-EIIF_NM-EI INDIVIDUAL SESSION BY NONMED PROF 74 314.50 15725.00 50.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 8 45.00 2250.00 50.00
HERN-EIIF_NM-EI HEARING SERVICES AFTER SHINE NONMED 10 24.00 1200.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 25 83.50 5667.98 67.88
OCCT-97530HM-OT SESSION BY OT ASST 1 1.50 101.82 67.88
PHY-97110-PT SESSION BY LICENSED PT 36 54.75 3716.43 67.88
PHY-97110HM-PT SESSION BY PT ASST 1 0.50 27.16 54.32
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 76 98.29 6672.15 67.88
SPL-92508-GROUP SPL SESSION PER CHILD 2 4.50 59.40 13.20
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 95 5520.00 2760.00 0.50
VISN-EIIF_NM-EI VISION SERVICES, IND NONMED 13 59.25 2962.50 50.00
Subtotal (Total Children Is Unduplicated) 335 7449.79 66549.94 8.93
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Total 7899.04 95778.69 12.13
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Number of Children (Unduplicated) With at Least One Service 562
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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
57 159.25 6937.50 0.00
Other 0 0.00 0.00 0.00
-------------------------------------------------
Total 57 159.25 6937.50 0.00
Center 02
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
2 162.25 7133.25 0.00
Other 0 0.00 0.00 0.00
-------------------------------------------------
Total 2 162.25 7133.25 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 2 3.00 74.90 184.26
T 0 0.00 0.00 0.00
154 960.50 32998.46 0.00
Other 0 0.00 0.00 0.00
-------------------------------------------------
Total 156 963.50 33073.36 184.26
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 217 1229.00 15598.25 15598.25
D 0 0.00 0.00 0.00
S 0 0.00 0.00 0.00
H 0 3.00 74.90 184.26
T 0 0.00 0.00 0.00
0 960.50 32998.46 0.00
Other 0 0.00 0.00 0.00
-------------------------------------------------
Total 217 2192.50 48671.61 15782.51
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 1229.00 15598.25 15598.25
D 0 0.00 0.00 0.00
S 0 0.00 0.00 0.00
H 0 3.00 74.90 184.26
T 0 0.00 0.00 0.00
7 967.25 33248.21 0.00
Other 0 0.00 0.00 0.00
-------------------------------------------------
Total 7 2199.25 48921.36 15782.51
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 1 1227.00 15448.25 15448.25
D 0 0.00 0.00 0.00
S 0 0.00 0.00 0.00
H 0 3.00 74.90 184.26
T 0 0.00 0.00 0.00
6 978.25 34073.21 0.00
Other 0 0.00 0.00 0.00
-------------------------------------------------
Total 7 2208.25 49596.36 15632.51
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 0 1227.00 15448.25 15448.25
D 0 0.00 0.00 0.00
S 0 0.00 0.00 0.00
H 0 3.00 74.90 184.26
T 0 0.00 0.00 0.00
292 1331.25 55695.37 0.00
Other 0 0.00 0.00 0.00
-------------------------------------------------
Total 292 2561.25 71218.52 15632.51
Center 10
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 1227.00 15448.25 15448.25
D 0 0.00 0.00 0.00
S 0 0.00 0.00 0.00
H 0 3.00 74.90 184.26
T 0 0.00 0.00 0.00
10 1708.75 57045.39 0.00
Other 0 0.00 0.00 0.00
-------------------------------------------------
Total 10 2938.75 72568.54 15632.51
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 23 2409.00 16289.39 16289.39
D 0 0.00 0.00 0.00
S 0 0.00 0.00 0.00
H 0 3.00 74.90 184.26
T 0 0.00 0.00 0.00
47 1783.50 61670.92 0.00
Other 0 0.00 0.00 0.00
-------------------------------------------------
Total 70 4195.50 78035.21 16473.65
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 2409.00 16289.39 16289.39
D 0 0.00 0.00 0.00
S 0 0.00 0.00 0.00
H 3 12.75 736.73 184.26
T 0 0.00 0.00 0.00
104 3395.54 66958.26 0.00
Other 0 0.00 0.00 0.00
-------------------------------------------------
Total 107 5817.29 83984.38 16473.65
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 2409.00 16289.39 16289.39
D 0 0.00 0.00 0.00
S 0 0.00 0.00 0.00
H 0 12.75 736.73 184.26
T 0 0.00 0.00 0.00
44 3435.04 68419.76 0.00
Other 0 0.00 0.00 0.00
-------------------------------------------------
Total 44 5856.79 85445.88 16473.65
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 2409.00 16289.39 16289.39
D 0 0.00 0.00 0.00
S 0 0.00 0.00 0.00
H 0 12.75 736.73 184.26
T 0 0.00 0.00 0.00
57 5022.29 74824.73 373.34
Other 52 455.00 3927.84 4064.54
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Total 109 7899.04 95778.69 20911.53