CMS/EIP Fiscal Report Statewide
Services beginning 07/01/2009 ending 09/30/2009 Date of Report:11/16/2009 Page: 1
Payclass Filters:GR
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 132 326.50 12080.50 37.00
TCON-TCON-TRANSITION CONFERENCE 5 5.00 0.00 0.00
Subtotal (Total Children Is Unduplicated) 297 534.25 17325.25 32.43
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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) 2 2.00 17.66 8.83
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 2 2.00 21.18 10.59
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 2 2.00 43.58 21.79
EVAL-EVAL-DEVELOPMENTAL EVALUATION 11 9.50 475.00 50.00
EXIT-EXIT-TRANSITION ASSESSMENT 1 1.50 75.00 50.00
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 3 2.00 118.45 59.23
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 1 0.50 37.50 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 1 0.50 27.75 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 2 1.50 112.50 75.00
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 1 1.00 185.00 185.00
Subtotal (Total Children Is Unduplicated) 20 25.50 1235.24 48.44
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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
EIIF-96154-HEALTH AND BEHAVIOR INTERVENTION 1 5.00 250.00 50.00
EIIF-EIIF_NM-EI INDIVIDUAL SESSION BY NONMED PROF 1 7.00 350.00 50.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 5 28.00 1400.00 50.00
INTR-INTR-INTERPRETER 4 6.00 297.00 49.50
OCCT-97530-OT SESSION BY LICENSED OT 2 2.25 152.73 67.88
PHY-97110-PT SESSION BY LICENSED PT 4 17.25 1170.93 67.88
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 2 5.50 373.34 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) 55 7250.75 8163.45 1.13
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Total 7810.50 26723.94 3.42
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Number of Children (Unduplicated) With at Least One Service 321
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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 64 2105.75 1898.31 1898.31
D 0 0.00 0.00 0.00
S 24 18.00 666.00 0.00
H 1 0.50 37.50 0.00
T 50 1869.50 1143.45 1143.45
228 146.75 4971.25 0.00
Other 4 32.00 150.76 0.00
-------------------------------------------------
Total 371 4172.50 8867.27 3041.76
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 12 2635.75 2509.81 2509.81
D 10 8.00 296.00 296.00
S 0 18.00 666.00 0.00
H 0 0.50 37.50 0.00
T 0 1869.50 1143.45 1143.45
396 347.00 12007.25 0.00
Other 0 32.00 150.76 0.00
-------------------------------------------------
Total 418 4910.75 16810.77 3949.26
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 0 2635.75 2509.81 2509.81
D 0 8.00 296.00 296.00
S 0 18.00 666.00 0.00
H 0 0.50 37.50 0.00
T 0 1869.50 1143.45 1143.45
109 405.75 13441.00 0.00
Other 0 32.00 150.76 0.00
-------------------------------------------------
Total 109 4969.50 18244.52 3949.26
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 47 3414.75 3478.69 3478.69
D 0 8.00 296.00 296.00
S 0 18.00 666.00 0.00
H 0 0.50 37.50 0.00
T 0 1869.50 1143.45 1143.45
153 784.75 16320.50 0.00
Other 0 32.00 150.76 0.00
-------------------------------------------------
Total 200 6127.50 22092.90 4918.14
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 11 3583.00 3898.80 3898.80
D 0 8.00 296.00 296.00
S 0 18.00 666.00 0.00
H 0 0.50 37.50 0.00
T 0 1869.50 1143.45 1143.45
10 795.25 16561.00 0.00
Other 0 32.00 150.76 0.00
-------------------------------------------------
Total 21 6306.25 22753.51 5338.25
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 24 4123.25 5426.42 5426.42
D 0 8.00 296.00 296.00
S 0 18.00 666.00 0.00
H 0 0.50 37.50 0.00
T 0 1869.50 1143.45 1143.45
41 822.50 17584.69 0.00
Other 0 32.00 150.76 0.00
-------------------------------------------------
Total 65 6873.75 25304.82 6865.87
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 4123.25 5426.42 5426.42
D 0 8.00 296.00 296.00
S 0 18.00 666.00 0.00
H 0 0.50 37.50 0.00
T 0 1869.50 1143.45 1143.45
4 849.75 17606.44 0.00
Other 0 32.00 150.76 0.00
-------------------------------------------------
Total 4 6901.00 25326.57 6865.87
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 4123.25 5426.42 5426.42
D 0 8.00 296.00 296.00
S 0 18.00 666.00 0.00
H 0 0.50 37.50 0.00
T 3 1930.00 1191.95 1191.95
31 1106.75 18346.44 0.00
Other 0 32.00 150.76 0.00
-------------------------------------------------
Total 34 7218.50 26115.07 6914.37
Center 54
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 4 4157.25 5489.54 5489.54
D 3 9.00 333.00 296.00
S 0 18.00 666.00 0.00
H 0 0.50 37.50 0.00
T 0 1930.00 1191.95 1191.95
8 1663.75 18855.19 0.00
Other 0 32.00 150.76 0.00
-------------------------------------------------
Total 15 7810.50 26723.94 6977.49