CMS/EIP Fiscal Report Statewide
Services beginning 07/01/2009 ending 09/30/2009 Date of Report:11/17/2009 Page: 1
Agency Filter:EXT
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
Screening, Eval, and Assessment,Class #02
EXIT-EXIT-TRANSITION ASSESSMENT 1 1.00 50.00 50.00
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 1 2.00 150.00 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 3 3.00 225.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 5 9.50 433.00 45.58
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 4 4.00 213.38 53.35
PSTH-97001-EVAL BY LICENSED PT, INITIAL 1 1.00 48.50 48.50
Subtotal (Total Children Is Unduplicated) 21 30.00 1676.38 55.88
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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 13 8.75 437.50 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 36 105.50 5275.00 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 14 60.50 4106.74 67.88
PHY-97110-PT SESSION BY LICENSED PT 30 67.50 4581.90 67.88
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 54 111.25 7551.65 67.88
SPL-92508-GROUP SPL SESSION PER CHILD 3 1.50 19.80 13.20
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 63 2387.00 2387.50 1.00
VISN-EIIF_NM-EI VISION SERVICES, IND NONMED 10 43.50 2175.00 50.00
Subtotal (Total Children Is Unduplicated) 258 4178.25 64942.25 15.54
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Total 4208.25 66618.63 15.83
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Number of Children (Unduplicated) With at Least One Service 266
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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
134 840.75 28151.80 0.00
Other 0 0.00 0.00 0.00
-------------------------------------------------
Total 135 843.25 28321.50 169.70
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
3 843.75 28376.80 0.00
Other 0 0.00 0.00 0.00
-------------------------------------------------
Total 220 1578.25 47754.18 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 0.00 0.00 0.00
H 0 2.50 169.70 169.70
T 0 0.00 0.00 0.00
8 865.75 29884.40 0.00
Other 0 0.00 0.00 0.00
-------------------------------------------------
Total 8 1600.25 49261.78 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 0.00 0.00 0.00
H 0 2.50 169.70 169.70
T 0 0.00 0.00 0.00
37 930.75 33880.86 0.00
Other 0 0.00 0.00 0.00
-------------------------------------------------
Total 37 1665.25 53258.24 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 0.00 0.00 0.00
H 0 2.50 169.70 169.70
T 0 0.00 0.00 0.00
77 1745.00 38745.30 0.00
Other 0 0.00 0.00 0.00
-------------------------------------------------
Total 77 2479.50 58122.68 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 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
9 1750.75 39082.01 0.00
Other 0 0.00 0.00 0.00
-------------------------------------------------
Total 9 2485.25 58459.39 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 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
2 1752.75 39182.01 0.00
Other 0 0.00 0.00 0.00
-------------------------------------------------
Total 2 2487.25 58559.39 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 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
85 3460.25 46414.27 0.00
Other 10 13.50 826.98 826.98
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Total 95 4208.25 66618.63 20204.36