CMS/EIP Fiscal Report Statewide
Services beginning 07/01/2009 ending 09/30/2009 Date of Report:11/16/2009 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 152 78.25 2895.25 37.00
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 59 61.00 0.00 0.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 68 63.50 2349.50 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 430 1254.25 46351.75 36.96
TCON-TCON-TRANSITION CONFERENCE 5 5.00 0.00 0.00
Subtotal (Total Children Is Unduplicated) 435 1462.00 51596.50 35.29
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Screening, Eval, and Assessment,Class #02
AUDE-92552-PURE TONE AUDIOMETRY -AIR ONLY 1 1.00 10.62 10.62
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 4 4.00 35.32 8.83
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 4 4.00 42.78 10.70
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 4 4.00 87.16 21.79
EVAL-EVAL-DEVELOPMENTAL EVALUATION 11 9.50 475.00 50.00
EXIT-EXIT-TRANSITION ASSESSMENT 1 1.50 75.00 50.00
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 1 1.50 112.50 75.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 1.50 112.50 75.00
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 2 3.00 225.00 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 5 4.00 300.00 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 4 5.00 277.50 55.50
IPDEI-IPDEI_NM-INITIAL PSYCH & DEV EVAL BY NON-MED PR 1 2.00 111.00 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 25 28.50 2100.00 73.68
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 8 8.00 600.00 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 16 16.00 1200.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 17 18.50 1026.75 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 26 23.50 1762.50 75.00
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 1 1.00 185.00 185.00
MED-99204-OUTPATIENT VISIT, NEW, 45 MINS 1 1.00 57.27 57.27
MED-99205-OUTPATIENT VISIT, NEW, 60 MINS 7 7.00 509.46 72.78
MED-99215-OUTPATIENT VISIT, EST, 40 MINS 10 10.00 501.50 50.15
PSTH-97001-EVAL BY LICENSED PT, INITIAL 2 2.00 97.00 48.50
SCREEN-T1023-INTERDISCIPLINARY SCREENING 17 17.00 850.00 50.00
Subtotal (Total Children Is Unduplicated) 84 173.50 10753.86 61.98
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 2 6.00 300.00 50.00
CONOF-CONOF-CONSULT, OT, FACE TO FACE 1 0.75 37.50 50.00
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 1 0.50 25.00 50.00
EIIF-96154-HEALTH AND BEHAVIOR INTERVENTION 1 5.00 250.00 50.00
EIIF-EIIF_NM-EI INDIVIDUAL SESSION BY NONMED PROF 2 10.00 500.00 50.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 25 138.00 6900.00 50.00
INTR-INTR-INTERPRETER 4 6.00 297.00 49.50
OCCT-97530-OT SESSION BY LICENSED OT 3 10.75 729.71 67.88
PHY-97110-PT SESSION BY LICENSED PT 10 34.50 2341.86 67.88
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 8 22.50 1527.30 67.88
TRAN-TRAN-FAMILY TRANSPORTATION 6 6.00 48.00 8.00
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 47 7167.00 3783.95 0.53
Subtotal (Total Children Is Unduplicated) 56 7407.00 16740.32 2.26
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Total 9042.50 79090.68 8.75
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Number of Children (Unduplicated) With at Least One Service 438
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Center 01
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 310 226.75 9201.50 0.00
P 114 2152.00 3609.56 3609.56
D 14 10.00 654.00 0.00
S 92 77.50 2867.50 0.00
H 11 8.50 637.50 0.00
T 50 1869.50 1143.45 1143.45
276 225.00 8753.85 0.00
Other 20 48.50 1313.26 0.00
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Total 887 4617.75 28180.62 4753.01
Center 04
Flag Claims Units Chgs Paid
-------------------------------------------------
R 0 0.00 0.00 0.00
U 0 0.00 0.00 0.00
B 90 289.00 11617.75 0.00
P 136 2784.75 8022.81 8022.81
D 10 18.00 950.00 296.00
S 0 77.50 2867.50 0.00
H 7 31.50 1803.88 1166.38
T 0 1869.50 1143.45 1143.45
396 425.25 15789.85 0.00
Other 0 48.50 1313.26 0.00
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Total 639 5544.00 43508.50 10628.64
Center 05
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 253 423.00 16601.90 0.00
P 8 2791.00 8293.06 8293.06
D 0 18.00 950.00 296.00
S 0 77.50 2867.50 0.00
H 0 31.50 1803.88 1166.38
T 0 1869.50 1143.45 1143.45
138 513.00 18834.41 0.00
Other 0 48.50 1313.26 0.00
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Total 399 5772.00 51807.46 10898.89
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 291 600.00 23150.90 0.00
P 47 3570.00 9261.94 9261.94
D 0 18.00 950.00 296.00
S 0 77.50 2867.50 0.00
H 0 31.50 1803.88 1166.38
T 0 1869.50 1143.45 1143.45
228 959.00 25718.74 0.00
Other 0 48.50 1313.26 0.00
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Total 566 7174.00 66209.67 11867.77
Center 10
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 14 610.75 23661.65 0.00
P 34 3765.50 10916.30 10916.30
D 0 18.00 950.00 296.00
S 19 87.00 3219.00 0.00
H 0 31.50 1803.88 1166.38
T 0 1869.50 1143.45 1143.45
14 977.00 26343.18 0.00
Other 0 48.50 1313.26 0.00
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Total 81 7407.75 69350.72 13522.13
Center 51
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 56 664.25 25641.15 0.00
P 24 4305.75 12443.92 12443.92
D 0 18.00 950.00 296.00
S 0 87.00 3219.00 0.00
H 0 31.50 1803.88 1166.38
T 0 1869.50 1143.45 1143.45
48 1018.75 28295.99 0.00
Other 0 48.50 1313.26 0.00
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Total 128 8043.25 74810.65 15049.75
Center 52
Flag Claims Units Chgs Paid
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R 1 1.00 75.00 0.00
U 0 0.00 0.00 0.00
B 6 668.75 25826.15 0.00
P 0 4305.75 12443.92 12443.92
D 0 18.00 950.00 296.00
S 4 91.25 3376.25 0.00
H 0 31.50 1803.88 1166.38
T 0 1869.50 1143.45 1143.45
4 1046.00 28317.74 0.00
Other 0 48.50 1313.26 0.00
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Total 15 8080.25 75249.65 15049.75
Center 53
Flag Claims Units Chgs Paid
-------------------------------------------------
R 0 1.00 75.00 0.00
U 0 0.00 0.00 0.00
B 14 680.50 26299.90 0.00
P 20 4322.25 13348.17 13348.17
D 0 18.00 950.00 296.00
S 0 91.25 3376.25 0.00
H 0 31.50 1803.88 1166.38
T 3 1930.00 1191.95 1191.95
38 1305.50 29150.24 0.00
Other 0 48.50 1313.26 0.00
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Total 75 8428.50 77508.65 16002.50
Center 54
Flag Claims Units Chgs Paid
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R 0 1.00 75.00 0.00
U 0 0.00 0.00 0.00
B 0 680.50 26299.90 0.00
P 43 4376.00 14246.04 14246.04
D 3 19.00 987.00 296.00
S 1 92.25 3426.25 0.00
H 0 31.50 1803.88 1166.38
T 0 1930.00 1191.95 1191.95
10 1863.75 29747.40 0.00
Other 0 48.50 1313.26 0.00
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Total 57 9042.50 79090.68 16900.37