CMS/EIP Fiscal Report Statewide
Services beginning 10/01/2009 ending 12/31/2009 Date of Report:02/16/2010 Page: 1
Agency Filter:EIP DEI DEIP
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-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-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 54 79.00 4384.50 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
Subtotal (Total Children Is Unduplicated) 113 240.50 18069.75 75.13
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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 1 1.00 50.00 50.00
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 1 0.25 12.50 50.00
CONOP-CONOP-CONSULT, OT, PHONE 1 0.50 12.50 25.00
CONSP-CONSP-CONSULT, SLP, PHONE 2 1.00 25.00 25.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 9 10.75 537.50 50.00
OCCT-97530-OT SESSION BY LICENSED OT 5 19.25 1306.69 67.88
PHY-97110-PT SESSION BY LICENSED PT 2 13.25 899.41 67.88
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 9 14.00 950.32 67.88
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 3 114.00 57.00 0.50
Subtotal (Total Children Is Unduplicated) 28 175.00 3865.92 22.09
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Total 879.75 38927.92 44.25
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Number of Children (Unduplicated) With at Least One Service 381
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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 16.00 2880.00 0.00
Other 0 0.00 0.00 0.00
-------------------------------------------------
Total 16 16.00 2880.00 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 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
6 27.00 3555.00 0.00
Other 0 0.00 0.00 0.00
-------------------------------------------------
Total 6 27.00 3555.00 0.00
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 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
7 36.00 4153.00 0.00
Other 0 0.00 0.00 0.00
-------------------------------------------------
Total 7 36.00 4153.00 0.00
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 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
439 395.50 18934.00 0.00
Other 0 0.00 0.00 0.00
-------------------------------------------------
Total 439 395.50 18934.00 0.00
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 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
1 466.50 18969.50 0.00
Other 0 0.00 0.00 0.00
-------------------------------------------------
Total 1 466.50 18969.50 0.00
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 0.00 0.00 0.00
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
24 522.25 19642.50 0.00
Other 0 0.00 0.00 0.00
-------------------------------------------------
Total 50 573.00 23061.42 0.00
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 0.00 0.00 0.00
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
159 632.00 24007.25 0.00
Other 0 0.00 0.00 0.00
-------------------------------------------------
Total 159 682.75 27426.17 0.00
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 0.00 0.00 0.00
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
5 638.50 24247.75 0.00
Other 0 0.00 0.00 0.00
-------------------------------------------------
Total 5 689.25 27666.67 0.00
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 0.00 0.00 0.00
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
155 829.00 35509.00 0.00
Other 0 0.00 0.00 0.00
-------------------------------------------------
Total 155 879.75 38927.92 0.00