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:Program Patients
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
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 2 1.00 37.00 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 251 672.00 24864.00 37.00
Subtotal (Total Children Is Unduplicated) 252 675.75 24928.75 36.89
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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 6 12.00 900.00 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 45 84.50 6337.50 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 43 70.50 5287.50 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 14 22.00 1650.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 11 19.00 960.25 50.54
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 4 8.00 600.00 75.00
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 26 26.00 4810.00 185.00
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 4 4.00 200.00 50.00
Subtotal (Total Children Is Unduplicated) 159 280.25 22989.63 82.03
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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 16 26.25 1312.50 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 75 336.50 16770.16 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) 281 4401.25 67556.41 15.35
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Total 5357.25 115474.79 21.55
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Number of Children (Unduplicated) With at Least One Service 663
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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
60 142.25 6337.50 0.00
Other 0 0.00 0.00 0.00
-------------------------------------------------
Total 60 142.25 6337.50 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
163 873.25 33451.80 0.00
Other 0 0.00 0.00 0.00
-------------------------------------------------
Total 164 875.75 33621.50 169.70
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 218 733.00 19282.68 19282.68
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
3 876.25 33676.80 0.00
Other 0 0.00 0.00 0.00
-------------------------------------------------
Total 221 1611.75 53129.18 19452.38
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 0 733.00 19282.68 19282.68
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
13 885.25 34009.80 0.00
Other 0 0.00 0.00 0.00
-------------------------------------------------
Total 13 1620.75 53462.18 19452.38
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 0 733.00 19282.68 19282.68
D 0 0.00 0.00 0.00
S 6 5.25 307.25 0.00
H 0 2.50 169.70 169.70
T 0 0.00 0.00 0.00
11 896.25 34681.80 0.00
Other 0 0.00 0.00 0.00
-------------------------------------------------
Total 17 1637.00 54441.43 19452.38
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 0 733.00 19282.68 19282.68
D 0 0.00 0.00 0.00
S 0 5.25 307.25 0.00
H 0 2.50 169.70 169.70
T 0 0.00 0.00 0.00
260 1222.75 53439.92 0.00
Other 0 0.00 0.00 0.00
-------------------------------------------------
Total 260 1963.50 73199.55 19452.38
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 0 733.00 19282.68 19282.68
D 0 0.00 0.00 0.00
S 0 5.25 307.25 0.00
H 0 2.50 169.70 169.70
T 0 0.00 0.00 0.00
37 1287.75 57436.38 0.00
Other 0 0.00 0.00 0.00
-------------------------------------------------
Total 37 2028.50 77196.01 19452.38
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 0 733.00 19282.68 19282.68
D 0 0.00 0.00 0.00
S 0 5.25 307.25 0.00
H 25 43.50 3024.26 169.70
T 0 0.00 0.00 0.00
91 2261.75 62727.90 0.00
Other 0 0.00 0.00 0.00
-------------------------------------------------
Total 116 3043.50 85342.09 19452.38
Center 53
Flag Claims Units Chgs Paid
-------------------------------------------------
R 0 0.00 0.00 0.00
U 0 0.00 0.00 0.00
B 223 217.00 8029.00 0.00
P 0 733.00 19282.68 19282.68
D 0 0.00 0.00 0.00
S 0 5.25 307.25 0.00
H 0 43.50 3024.26 169.70
T 0 0.00 0.00 0.00
408 2630.25 76486.36 0.00
Other 0 0.00 0.00 0.00
-------------------------------------------------
Total 631 3629.00 107129.55 19452.38
Center 55
Flag Claims Units Chgs Paid
-------------------------------------------------
R 0 0.00 0.00 0.00
U 0 0.00 0.00 0.00
B 0 217.00 8029.00 0.00
P 0 733.00 19282.68 19282.68
D 0 0.00 0.00 0.00
S 0 5.25 307.25 0.00
H 0 43.50 3024.26 169.70
T 0 0.00 0.00 0.00
4 2634.00 76614.11 0.00
Other 0 0.00 0.00 0.00
-------------------------------------------------
Total 4 3632.75 107257.30 19452.38
Center 57
Flag Claims Units Chgs Paid
-------------------------------------------------
R 0 0.00 0.00 0.00
U 0 0.00 0.00 0.00
B 0 217.00 8029.00 0.00
P 0 733.00 19282.68 19282.68
D 0 0.00 0.00 0.00
S 0 5.25 307.25 0.00
H 0 43.50 3024.26 169.70
T 0 0.00 0.00 0.00
88 4345.00 84004.62 0.00
Other 10 13.50 826.98 826.98
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Total 98 5357.25 115474.79 20279.36