CMS/EIP Fiscal Report Statewide
Services beginning 10/01/2009 ending 12/31/2009 Date of Report:02/16/2010 Page: 1
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 5 3.75 138.75 37.00
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 5 5.00 0.00 0.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 1 1.00 37.00 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 249 454.50 16816.50 37.00
Subtotal (Total Children Is Unduplicated) 254 464.25 16992.25 36.60
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 6 9.00 675.00 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 1 2.00 150.00 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 4 5.50 305.25 55.50
IPDEI-IPDEI_NM-INITIAL PSYCH & DEV EVAL BY NON-MED PR 3 3.00 166.50 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 71 91.50 6862.50 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 8 12.00 900.00 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 3 3.50 262.50 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 61 92.50 5133.75 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 13 25.50 1912.50 75.00
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 15 15.00 2775.00 185.00
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 1 1.00 105.00 105.00
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 4 4.00 194.00 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 1 1.00 48.50 48.50
SPCH-92506-SPEECH EVAL BY LICENSED SLP 1 1.00 48.50 48.50
VISF-VISF-VISION EVALUATION FUNCTIONAL 1 0.50 25.00 50.00
Subtotal (Total Children Is Unduplicated) 131 267.00 19564.00 73.27
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 1 1.00 15.00 15.00
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 5 7.00 350.00 50.00
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 30 27.50 1375.00 50.00
CONIP-CONIP-CONSULT, ITDS, PHONE 9 9.00 225.00 25.00
CONOP-CONOP-CONSULT, OT, PHONE 1 0.50 12.50 25.00
CONPF-CONPF-CONSULT, PT, FACE TO FACE 4 2.50 125.00 50.00
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 37 34.50 1725.00 50.00
CONSP-CONSP-CONSULT, SLP, PHONE 10 7.50 187.50 25.00
ECE-ECE-EARLY CHILDHOOD EDUCATION 2 384.00 3456.00 9.00
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 8 50.50 1262.50 25.00
EIIF-EIIF_NM-EI INDIVIDUAL SESSION BY NONMED PROF 36 201.25 10042.50 49.90
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 30 138.50 6925.00 50.00
HERN-EIIF_NM-EI HEARING SERVICES AFTER SHINE NONMED 11 43.00 2150.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 19 80.75 5345.55 66.20
PHY-97110-PT SESSION BY LICENSED PT 9 33.75 2290.95 67.88
SHIN-T1027SC-INITIAL SHINE SERVICES, INDIVIDUAL 1 1.00 50.00 50.00
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 24 44.76 3038.14 67.88
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 87 4940.00 2470.00 0.50
VISN-EIIF_NM-EI VISION SERVICES, IND NONMED 14 75.50 3775.00 50.00
Subtotal (Total Children Is Unduplicated) 249 6082.51 44820.64 7.37
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Total 6813.76 81376.89 11.94
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Number of Children (Unduplicated) With at Least One Service 612
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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
38 156.00 6975.00 0.00
Other 0 0.00 0.00 0.00
-------------------------------------------------
Total 38 156.00 6975.00 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 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
16 172.00 9855.00 0.00
Other 0 0.00 0.00 0.00
-------------------------------------------------
Total 16 172.00 9855.00 0.00
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 54 119.00 5873.50 5873.50
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
98 862.00 19299.75 0.00
Other 0 0.00 0.00 0.00
-------------------------------------------------
Total 152 981.00 25173.25 5873.50
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 0 119.00 5873.50 5873.50
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
1 862.50 19333.69 0.00
Other 0 0.00 0.00 0.00
-------------------------------------------------
Total 1 981.50 25207.19 5873.50
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 0 119.00 5873.50 5873.50
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
10 881.50 20610.49 0.00
Other 0 0.00 0.00 0.00
-------------------------------------------------
Total 10 1000.50 26483.99 5873.50
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 0 119.00 5873.50 5873.50
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
445 1254.00 36273.93 0.00
Other 0 0.00 0.00 0.00
-------------------------------------------------
Total 445 1373.00 42147.43 5873.50
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 0 119.00 5873.50 5873.50
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
44 1413.00 41320.13 0.00
Other 0 0.00 0.00 0.00
-------------------------------------------------
Total 44 1532.00 47193.63 5873.50
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 0 119.00 5873.50 5873.50
D 0 0.00 0.00 0.00
S 0 0.00 0.00 0.00
H 26 50.75 3418.92 0.00
T 0 0.00 0.00 0.00
130 3083.76 46074.45 0.00
Other 0 0.00 0.00 0.00
-------------------------------------------------
Total 156 3253.51 55366.87 5873.50
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 0 119.00 5873.50 5873.50
D 0 0.00 0.00 0.00
S 0 0.00 0.00 0.00
H 0 50.75 3418.92 0.00
T 0 0.00 0.00 0.00
162 3239.51 50511.70 0.00
Other 0 0.00 0.00 0.00
-------------------------------------------------
Total 162 3409.26 59804.12 5873.50
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 0 119.00 5873.50 5873.50
D 0 0.00 0.00 0.00
S 0 0.00 0.00 0.00
H 0 50.75 3418.92 0.00
T 0 0.00 0.00 0.00
5 3246.01 50752.20 0.00
Other 0 0.00 0.00 0.00
-------------------------------------------------
Total 5 3415.76 60044.62 5873.50
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 0 119.00 5873.50 5873.50
D 0 0.00 0.00 0.00
S 0 0.00 0.00 0.00
H 0 50.75 3418.92 0.00
T 2 5.00 250.00 250.00
255 6328.51 68273.19 0.00
Other 86 310.50 3561.28 3561.28
-------------------------------------------------
Total 343 6813.76 81376.89 9684.78