CMS/EIP Fiscal Report Statewide
Services beginning 10/01/2009 ending 12/31/2009 Date of Report:02/16/2010 Page: 1
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 142 76.75 2839.75 37.00
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 50 50.00 0.00 0.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 54 71.25 2636.25 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 448 1063.00 39257.00 36.93
TCON-TCON-TRANSITION CONFERENCE 3 3.00 0.00 0.00
Subtotal (Total Children Is Unduplicated) 451 1264.00 44733.00 35.39
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Screening, Eval, and Assessment,Class #02
EVAL-EVAL-DEVELOPMENTAL EVALUATION 6 7.50 375.00 50.00
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 1.50 112.50 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 1 1.50 112.50 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 2 2.00 111.00 55.50
IPDEI-IPDEI_NM-INITIAL PSYCH & DEV EVAL BY NON-MED PR 2 4.00 222.00 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 9 12.50 937.50 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 6 7.00 525.00 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 1 1.50 112.50 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 10 14.00 777.00 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 9 10.50 787.50 75.00
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 1 1.00 185.00 185.00
MED-99204-OUTPATIENT VISIT, NEW, 45 MINS 2 2.00 550.00 275.00
MED-99205-OUTPATIENT VISIT, NEW, 60 MINS 3 3.00 218.34 72.78
MED-99215-OUTPATIENT VISIT, EST, 40 MINS 6 6.00 300.90 50.15
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 1 1.00 48.50 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 1 1.00 48.50 48.50
SCREEN-T1023-INTERDISCIPLINARY SCREENING 9 9.00 450.00 50.00
Subtotal (Total Children Is Unduplicated) 38 85.00 5873.74 69.10
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 1 2.00 309.42 154.71
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 4 8.25 412.50 50.00
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 1 0.75 37.50 50.00
CONPF-CONPF-CONSULT, PT, FACE TO FACE 1 0.25 12.50 50.00
EIIF-96154-HEALTH AND BEHAVIOR INTERVENTION 1 7.00 350.00 50.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 23 151.00 7550.00 50.00
INTR-INTR-INTERPRETER 1 1.00 30.00 30.00
OCCT-97530-OT SESSION BY LICENSED OT 4 21.50 1459.42 67.88
PHY-97110-PT SESSION BY LICENSED PT 9 42.25 2867.93 67.88
PHY-97110HM-PT SESSION BY PT ASST 1 3.50 190.12 54.32
SHIN-T1027SC-INITIAL SHINE SERVICES, INDIVIDUAL 1 1.00 50.00 50.00
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 9 20.25 1413.70 69.81
TRAN-TRAN-FAMILY TRANSPORTATION 7 7.00 56.00 8.00
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 42 6882.00 3610.80 0.52
Subtotal (Total Children Is Unduplicated) 55 7147.75 18349.89 2.57
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Total 8496.75 68956.63 8.12
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Number of Children (Unduplicated) With at Least One Service 455
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Center 01
Flag Claims Units Chgs Paid
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R 12 7.00 259.00 0.00
U 0 0.00 0.00 0.00
B 250 211.25 7742.25 0.00
P 71 2095.00 2176.73 2176.73
D 10 9.25 513.25 0.00
S 117 74.00 2738.00 0.00
H 0 0.00 0.00 0.00
T 39 1331.00 1284.20 1284.20
202 244.75 7853.01 50.00
Other 17 294.25 1557.66 0.00
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Total 718 4266.50 24124.10 3510.93
Center 04
Flag Claims Units Chgs Paid
-------------------------------------------------
R 23 27.25 1008.25 0.00
U 0 0.00 0.00 0.00
B 124 286.50 10658.00 0.00
P 99 2590.25 4367.98 4367.98
D 0 9.25 513.25 0.00
S 0 74.00 2738.00 0.00
H 9 33.00 1793.04 1793.04
T 0 1331.00 1284.20 1284.20
392 442.50 15336.26 50.00
Other 0 294.25 1557.66 0.00
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Total 647 5088.00 39256.64 7495.22
Center 05
Flag Claims Units Chgs Paid
-------------------------------------------------
R 0 27.25 1008.25 0.00
U 0 0.00 0.00 0.00
B 199 397.25 14768.90 0.00
P 1 2591.25 4417.98 4417.98
D 0 9.25 513.25 0.00
S 0 74.00 2738.00 0.00
H 0 33.00 1793.04 1793.04
T 0 1331.00 1284.20 1284.20
129 514.50 17711.35 50.00
Other 0 294.25 1557.66 0.00
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Total 329 5271.75 45792.63 7545.22
Center 06
Flag Claims Units Chgs Paid
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R 1 27.75 1026.75 0.00
U 0 0.00 0.00 0.00
B 15 406.75 15120.40 0.00
P 271 3165.25 9879.98 9879.98
D 0 9.25 513.25 0.00
S 0 74.00 2738.00 0.00
H 0 33.00 1793.04 1793.04
T 0 1331.00 1284.20 1284.20
195 898.00 22733.37 142.50
Other 0 294.25 1557.66 0.00
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Total 482 6239.25 56646.65 13099.72
Center 10
Flag Claims Units Chgs Paid
-------------------------------------------------
R 3 29.75 1100.75 0.00
U 0 0.00 0.00 0.00
B 8 411.75 15305.40 0.00
P 4 3167.50 10009.55 10009.55
D 0 9.25 513.25 0.00
S 3 75.00 2775.00 0.00
H 0 33.00 1793.04 1793.04
T 0 1331.00 1284.20 1284.20
24 928.25 24451.52 142.50
Other 0 294.25 1557.66 0.00
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Total 42 6279.75 58790.37 13229.29
Center 51
Flag Claims Units Chgs Paid
-------------------------------------------------
R 0 29.75 1100.75 0.00
U 0 0.00 0.00 0.00
B 32 433.50 16121.65 0.00
P 13 3398.00 10736.97 10736.97
D 0 9.25 513.25 0.00
S 0 75.00 2775.00 0.00
H 0 33.00 1793.04 1793.04
T 0 1331.00 1284.20 1284.20
27 951.00 25669.11 142.50
Other 0 294.25 1557.66 0.00
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Total 72 6554.75 61551.63 13956.71
Center 52
Flag Claims Units Chgs Paid
-------------------------------------------------
R 0 29.75 1100.75 0.00
U 0 0.00 0.00 0.00
B 6 438.50 16306.65 0.00
P 8 3402.50 10903.47 10903.47
D 0 9.25 513.25 0.00
S 0 75.00 2775.00 0.00
H 0 33.00 1793.04 1793.04
T 0 1331.00 1284.20 1284.20
11 1044.75 26059.61 142.50
Other 0 294.25 1557.66 0.00
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Total 25 6658.00 62293.63 14123.21
Center 53
Flag Claims Units Chgs Paid
-------------------------------------------------
R 19 46.75 1818.75 0.00
U 0 0.00 0.00 0.00
B 12 451.25 16778.40 0.00
P 15 3416.50 11651.47 11651.47
D 0 9.25 513.25 0.00
S 0 75.00 2775.00 0.00
H 2 149.00 1851.04 1851.04
T 2 1481.00 1359.20 1359.20
55 1900.00 28580.86 142.50
Other 0 294.25 1557.66 0.00
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Total 105 7823.00 66885.63 15004.21
Center 54
Flag Claims Units Chgs Paid
-------------------------------------------------
R 0 46.75 1818.75 0.00
U 0 0.00 0.00 0.00
B 19 464.75 17394.90 0.00
P 26 3782.00 12413.62 12413.62
D 3 10.00 541.00 0.00
S 0 75.00 2775.00 0.00
H 0 149.00 1851.04 1851.04
T 0 1481.00 1359.20 1359.20
15 2193.50 29226.96 142.50
Other 0 294.25 1557.66 0.00
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Total 63 8496.25 68938.13 15766.36
Center 55
Flag Claims Units Chgs Paid
-------------------------------------------------
R 0 46.75 1818.75 0.00
U 0 0.00 0.00 0.00
B 0 464.75 17394.90 0.00
P 0 3782.00 12413.62 12413.62
D 0 10.00 541.00 0.00
S 0 75.00 2775.00 0.00
H 0 149.00 1851.04 1851.04
T 0 1481.00 1359.20 1359.20
1 2194.00 29245.46 142.50
Other 0 294.25 1557.66 0.00
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Total 1 8496.75 68956.63 15766.36