CMS/EIP Fiscal Report Statewide
Services beginning 10/01/2009 ending 12/31/2009 Date of Report:02/16/2010 Page: 1
Agency Filter:EXT
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
Screening, Eval, and Assessment,Class #02
IPDEI-IPDEI_NM-INITIAL PSYCH & DEV EVAL BY NON-MED PR 3 3.00 166.50 55.50
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 7 13.50 749.25 55.50
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) 18 26.50 1494.25 56.39
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 4 6.00 300.00 50.00
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 29 27.25 1362.50 50.00
CONIP-CONIP-CONSULT, ITDS, PHONE 9 9.00 225.00 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 8 6.50 162.50 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 21 127.75 6387.50 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 14 61.50 4038.86 65.67
PHY-97110-PT SESSION BY LICENSED PT 7 20.50 1391.54 67.88
SHIN-T1027SC-INITIAL SHINE SERVICES, INDIVIDUAL 1 1.00 50.00 50.00
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 15 30.76 2087.82 67.87
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 84 4826.00 2413.00 0.50
VISN-EIIF_NM-EI VISION SERVICES, IND NONMED 14 75.50 3775.00 50.00
Subtotal (Total Children Is Unduplicated) 222 5907.51 40954.72 6.93
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Total 5934.01 42448.97 7.15
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Number of Children (Unduplicated) With at Least One Service 233
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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 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
92 835.00 15744.75 0.00
Other 0 0.00 0.00 0.00
-------------------------------------------------
Total 146 954.00 21618.25 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
1 835.50 15778.69 0.00
Other 0 0.00 0.00 0.00
-------------------------------------------------
Total 1 954.50 21652.19 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
3 845.50 16457.49 0.00
Other 0 0.00 0.00 0.00
-------------------------------------------------
Total 3 964.50 22330.99 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
6 858.50 17339.93 0.00
Other 0 0.00 0.00 0.00
-------------------------------------------------
Total 6 977.50 23213.43 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
43 946.50 22350.63 0.00
Other 0 0.00 0.00 0.00
-------------------------------------------------
Total 43 1065.50 28224.13 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 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
106 2561.51 26431.95 0.00
Other 0 0.00 0.00 0.00
-------------------------------------------------
Total 106 2680.51 32305.45 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 0.00 0.00 0.00
T 0 0.00 0.00 0.00
3 2607.51 26504.45 0.00
Other 0 0.00 0.00 0.00
-------------------------------------------------
Total 3 2726.51 32377.95 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 0.00 0.00 0.00
T 2 5.00 250.00 250.00
100 5499.51 32764.19 0.00
Other 86 310.50 3561.28 3561.28
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Total 188 5934.01 42448.97 9684.78