CMS/EIP Fiscal Report Statewide
Services beginning 07/01/2009 ending 09/30/2009 Date of Report:11/16/2009 Page: 1
Agency Filter:EIP DEI DEIP
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 4 3.75 187.50 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-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 35 66.50 4987.50 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 5 10.00 750.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 3 5.50 305.25 55.50
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
PSTH-97001-EVAL BY LICENSED PT, INITIAL 1 1.00 48.50 48.50
SCREEN-T1023-INTERDISCIPLINARY SCREENING 1 1.00 50.00 50.00
Subtotal (Total Children Is Unduplicated) 99 193.25 16201.25 83.84
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EI Services,Class #03
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 1 0.25 12.50 50.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 2 3.25 162.50 50.00
OCCT-97530-OT SESSION BY LICENSED OT 7 13.75 933.35 67.88
PHY-97110-PT SESSION BY LICENSED PT 2 1.75 118.79 67.88
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 7 16.50 1120.02 67.88
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 7 184.00 92.00 0.50
Subtotal (Total Children Is Unduplicated) 24 219.50 2439.16 11.11
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Total 1037.50 41682.16 40.18
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Number of Children (Unduplicated) With at Least One Service 344
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Center 04
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 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
20 20.00 3460.00 0.00
Other 0 0.00 0.00 0.00
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Total 20 20.00 3460.00 0.00
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 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
3 22.00 3534.00 0.00
Other 0 0.00 0.00 0.00
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Total 3 22.00 3534.00 0.00
Center 07
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 0 0.00 0.00 0.00
P 0 0.00 0.00 0.00
D 0 0.00 0.00 0.00
S 4 1.25 46.25 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
9 31.75 4159.75 0.00
Other 0 0.00 0.00 0.00
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Total 13 33.00 4206.00 0.00
Center 09
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 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 1.25 46.25 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
229 303.75 19067.27 0.00
Other 0 0.00 0.00 0.00
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Total 229 305.00 19113.52 0.00
Center 52
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 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 1.25 46.25 0.00
H 18 30.50 2086.56 0.00
T 0 0.00 0.00 0.00
14 463.50 19494.35 0.00
Other 0 0.00 0.00 0.00
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Total 32 495.25 21627.16 0.00
Center 53
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 207 201.75 7464.75 0.00
P 0 0.00 0.00 0.00
D 0 0.00 0.00 0.00
S 0 1.25 46.25 0.00
H 0 30.50 2086.56 0.00
T 0 0.00 0.00 0.00
364 798.75 31898.60 0.00
Other 0 0.00 0.00 0.00
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Total 571 1032.25 41496.16 0.00
Center 55
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 0 201.75 7464.75 0.00
P 0 0.00 0.00 0.00
D 0 0.00 0.00 0.00
S 0 1.25 46.25 0.00
H 0 30.50 2086.56 0.00
T 0 0.00 0.00 0.00
2 800.50 31926.35 0.00
Other 0 0.00 0.00 0.00
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Total 2 1034.00 41523.91 0.00
Center 57
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 0 201.75 7464.75 0.00
P 0 0.00 0.00 0.00
D 0 0.00 0.00 0.00
S 0 1.25 46.25 0.00
H 0 30.50 2086.56 0.00
T 0 0.00 0.00 0.00
3 804.00 32084.60 0.00
Other 0 0.00 0.00 0.00
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Total 3 1037.50 41682.16 0.00