CMS/EIP Fiscal Report Statewide
Services beginning 07/01/2009 ending 09/30/2009 Date of Report:11/17/2009 Page: 1
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
CASE-CASE-NON-TCM CASE MANAGEMENT 2 0.75 27.75 37.00
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 2 2.00 0.00 0.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 233 622.00 23014.00 37.00
Subtotal (Total Children Is Unduplicated) 234 624.75 23041.75 36.88
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Screening, Eval, and Assessment,Class #02
EXIT-EXIT-TRANSITION ASSESSMENT 5 4.75 237.50 50.00
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 5 10.00 750.00 75.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 6 11.00 825.00 75.00
IPDEI-IPDEI_NM-INITIAL PSYCH & DEV EVAL BY NON-MED PR 7 9.50 556.50 58.58
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 36 68.50 5137.50 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 33 58.50 4387.50 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 8 13.00 975.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 8 15.00 738.25 49.22
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 3 6.00 450.00 75.00
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 17 17.00 3145.00 185.00
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 3 3.00 315.00 105.00
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 4 4.00 213.38 53.35
PSTH-97001-EVAL BY LICENSED PT, INITIAL 2 2.00 97.00 48.50
SCREEN-T1023-INTERDISCIPLINARY SCREENING 1 1.00 50.00 50.00
Subtotal (Total Children Is Unduplicated) 120 223.25 17877.63 80.08
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 3 2.00 100.00 50.00
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 14 9.00 450.00 50.00
CONOP-CONOP-CONSULT, OT, PHONE 1 0.25 6.25 25.00
CONPP-CONPP-CONSULT, PT, PHONE 1 0.25 6.25 25.00
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 15 25.75 1287.50 50.00
CONSP-CONSP-CONSULT, SLP, PHONE 1 1.00 25.00 25.00
ECE-ECE-EARLY CHILDHOOD EDUCATION 5 368.00 3312.00 9.00
EIGF-EIGF_NM-EI GROUP SESSION BY NONMED PROF 3 46.00 1150.00 25.00
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 43 596.00 14900.00 25.00
EIIF-EIIF_NM-EI INDIVIDUAL SESSION BY NONMED PROF 74 333.50 16620.16 49.84
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 38 108.75 5437.50 50.00
HERN-EIIF_NM-EI HEARING SERVICES AFTER SHINE NONMED 6 20.00 1000.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 21 74.25 5040.09 67.88
PHY-97110-PT SESSION BY LICENSED PT 32 69.25 4700.69 67.88
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 61 127.75 8671.67 67.88
SPL-92508-GROUP SPL SESSION PER CHILD 3 1.50 19.80 13.20
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 70 2571.00 2479.50 0.96
VISN-EIIF_NM-EI VISION SERVICES, IND NONMED 10 43.50 2175.00 50.00
Subtotal (Total Children Is Unduplicated) 280 4397.75 67381.41 15.32
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Total 5245.75 108300.79 20.65
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Number of Children (Unduplicated) With at Least One Service 605
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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
58 138.75 6162.50 0.00
Other 0 0.00 0.00 0.00
-------------------------------------------------
Total 58 138.75 6162.50 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 1 2.50 169.70 169.70
T 0 0.00 0.00 0.00
154 860.75 31611.80 0.00
Other 0 0.00 0.00 0.00
-------------------------------------------------
Total 155 863.25 31781.50 169.70
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 217 732.00 19207.68 19207.68
D 0 0.00 0.00 0.00
S 0 0.00 0.00 0.00
H 0 2.50 169.70 169.70
T 0 0.00 0.00 0.00
3 863.75 31836.80 0.00
Other 0 0.00 0.00 0.00
-------------------------------------------------
Total 220 1598.25 51214.18 19377.38
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 0 732.00 19207.68 19207.68
D 0 0.00 0.00 0.00
S 0 0.00 0.00 0.00
H 0 2.50 169.70 169.70
T 0 0.00 0.00 0.00
3 865.75 31910.80 0.00
Other 0 0.00 0.00 0.00
-------------------------------------------------
Total 3 1600.25 51288.18 19377.38
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 0 732.00 19207.68 19207.68
D 0 0.00 0.00 0.00
S 4 1.25 46.25 0.00
H 0 2.50 169.70 169.70
T 0 0.00 0.00 0.00
9 875.50 32536.55 0.00
Other 0 0.00 0.00 0.00
-------------------------------------------------
Total 13 1611.25 51960.18 19377.38
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 0 732.00 19207.68 19207.68
D 0 0.00 0.00 0.00
S 0 1.25 46.25 0.00
H 0 2.50 169.70 169.70
T 0 0.00 0.00 0.00
237 1169.50 48951.67 0.00
Other 0 0.00 0.00 0.00
-------------------------------------------------
Total 237 1905.25 68375.30 19377.38
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 0 732.00 19207.68 19207.68
D 0 0.00 0.00 0.00
S 0 1.25 46.25 0.00
H 0 2.50 169.70 169.70
T 0 0.00 0.00 0.00
37 1234.50 52948.13 0.00
Other 0 0.00 0.00 0.00
-------------------------------------------------
Total 37 1970.25 72371.76 19377.38
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 0 732.00 19207.68 19207.68
D 0 0.00 0.00 0.00
S 0 1.25 46.25 0.00
H 18 33.00 2256.26 169.70
T 0 0.00 0.00 0.00
91 2208.50 58239.65 0.00
Other 0 0.00 0.00 0.00
-------------------------------------------------
Total 109 2974.75 79749.84 19377.38
Center 53
Flag Claims Units Chgs Paid
-------------------------------------------------
R 0 0.00 0.00 0.00
U 0 0.00 0.00 0.00
B 207 201.75 7464.75 0.00
P 0 732.00 19207.68 19207.68
D 0 0.00 0.00 0.00
S 0 1.25 46.25 0.00
H 0 33.00 2256.26 169.70
T 0 0.00 0.00 0.00
373 2549.50 70980.61 0.00
Other 0 0.00 0.00 0.00
-------------------------------------------------
Total 580 3517.50 99955.55 19377.38
Center 55
Flag Claims Units Chgs Paid
-------------------------------------------------
R 0 0.00 0.00 0.00
U 0 0.00 0.00 0.00
B 0 201.75 7464.75 0.00
P 0 732.00 19207.68 19207.68
D 0 0.00 0.00 0.00
S 0 1.25 46.25 0.00
H 0 33.00 2256.26 169.70
T 0 0.00 0.00 0.00
4 2553.25 71108.36 0.00
Other 0 0.00 0.00 0.00
-------------------------------------------------
Total 4 3521.25 100083.30 19377.38
Center 57
Flag Claims Units Chgs Paid
-------------------------------------------------
R 0 0.00 0.00 0.00
U 0 0.00 0.00 0.00
B 0 201.75 7464.75 0.00
P 0 732.00 19207.68 19207.68
D 0 0.00 0.00 0.00
S 0 1.25 46.25 0.00
H 0 33.00 2256.26 169.70
T 0 0.00 0.00 0.00
88 4264.25 78498.87 0.00
Other 10 13.50 826.98 826.98
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Total 98 5245.75 108300.79 20204.36