CMS/EIP Fiscal Report Statewide
Services beginning 10/01/2009 ending 12/31/2009 Date of Report:02/16/2010 Page: 1
Payclass Filters:GR
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 131 274.50 10156.50 37.00
TCON-TCON-TRANSITION CONFERENCE 3 3.00 0.00 0.00
Subtotal (Total Children Is Unduplicated) 279 475.50 15632.50 32.88
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Screening, Eval, and Assessment,Class #02
EVAL-EVAL-DEVELOPMENTAL EVALUATION 5 4.50 225.00 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
IPDEI-IPDEI_NM-INITIAL PSYCH & DEV EVAL BY NON-MED PR 2 4.00 222.00 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 2 1.50 112.50 75.00
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 1 1.00 48.50 48.50
Subtotal (Total Children Is Unduplicated) 11 14.00 833.00 59.50
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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 4 27.00 1350.00 50.00
INTR-INTR-INTERPRETER 1 1.00 30.00 30.00
PHY-97110-PT SESSION BY LICENSED PT 1 1.00 67.88 67.88
PHY-97110HM-PT SESSION BY PT ASST 1 3.50 190.12 54.32
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 4 6.75 446.94 66.21
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) 51 6946.50 6873.66 0.99
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Total 7436.00 23339.16 3.14
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Number of Children (Unduplicated) With at Least One Service 296
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Center 01
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 70 2094.00 2126.73 2126.73
D 0 0.00 0.00 0.00
S 6 3.25 120.25 0.00
H 0 0.00 0.00 0.00
T 39 1331.00 1284.20 1284.20
177 180.25 4337.75 0.00
Other 8 274.75 323.00 0.00
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Total 300 3883.25 8191.93 3410.93
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 9 2536.00 2347.73 2347.73
D 0 0.00 0.00 0.00
S 0 3.25 120.25 0.00
H 0 0.00 0.00 0.00
T 0 1331.00 1284.20 1284.20
378 365.00 10716.00 0.00
Other 0 274.75 323.00 0.00
-------------------------------------------------
Total 387 4510.00 14791.18 3631.93
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 0 2536.00 2347.73 2347.73
D 0 0.00 0.00 0.00
S 0 3.25 120.25 0.00
H 0 0.00 0.00 0.00
T 0 1331.00 1284.20 1284.20
111 419.00 12122.00 0.00
Other 0 274.75 323.00 0.00
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Total 111 4564.00 16197.18 3631.93
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 23 2975.00 2814.73 2814.73
D 0 0.00 0.00 0.00
S 0 3.25 120.25 0.00
H 0 0.00 0.00 0.00
T 0 1331.00 1284.20 1284.20
148 766.25 14796.94 92.50
Other 0 274.75 323.00 0.00
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Total 171 5350.25 19339.12 4191.43
Center 10
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 1 2976.50 2916.55 2916.55
D 0 0.00 0.00 0.00
S 0 3.25 120.25 0.00
H 0 0.00 0.00 0.00
T 0 1331.00 1284.20 1284.20
13 776.00 15083.69 92.50
Other 0 274.75 323.00 0.00
-------------------------------------------------
Total 14 5361.50 19727.69 4293.25
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 13 3207.00 3643.97 3643.97
D 0 0.00 0.00 0.00
S 0 3.25 120.25 0.00
H 0 0.00 0.00 0.00
T 0 1331.00 1284.20 1284.20
23 786.00 15453.69 92.50
Other 0 274.75 323.00 0.00
-------------------------------------------------
Total 36 5602.00 20825.11 5020.67
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 3207.00 3643.97 3643.97
D 0 0.00 0.00 0.00
S 0 3.25 120.25 0.00
H 0 0.00 0.00 0.00
T 0 1331.00 1284.20 1284.20
8 875.75 15598.44 92.50
Other 0 274.75 323.00 0.00
-------------------------------------------------
Total 8 5691.75 20969.86 5020.67
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 3207.00 3643.97 3643.97
D 0 0.00 0.00 0.00
S 0 3.25 120.25 0.00
H 2 116.00 58.00 58.00
T 2 1481.00 1359.20 1359.20
37 1712.50 17214.19 92.50
Other 0 274.75 323.00 0.00
-------------------------------------------------
Total 41 6794.50 22718.61 5153.67
Center 54
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 6 3559.25 3902.87 3902.87
D 3 0.75 27.75 0.00
S 0 3.25 120.25 0.00
H 0 116.00 58.00 58.00
T 0 1481.00 1359.20 1359.20
10 2000.50 17529.59 92.50
Other 0 274.75 323.00 0.00
-------------------------------------------------
Total 19 7435.50 23320.66 5412.57
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 3559.25 3902.87 3902.87
D 0 0.75 27.75 0.00
S 0 3.25 120.25 0.00
H 0 116.00 58.00 58.00
T 0 1481.00 1359.20 1359.20
1 2001.00 17548.09 92.50
Other 0 274.75 323.00 0.00
-------------------------------------------------
Total 1 7436.00 23339.16 5412.57