CMS/EIP Fiscal Report Statewide
Services beginning 10/01/2009 ending 12/31/2009 Date of Report:02/16/2010 Page: 1
Payclass Filters:LEA
Eligibility Filter:Program Patients
List order: No List
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 2 3.00 100.00 33.33
IPDEI-IPDEI_NM-INITIAL PSYCH & DEV EVAL BY NON-MED PR 16 16.00 882.50 55.16
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 19 29.00 1050.00 36.21
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 1 1.50 50.00 33.33
Subtotal (Total Children Is Unduplicated) 37 49.50 2082.50 42.07
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 2 2.50 100.00 40.00
ECE-ECE-EARLY CHILDHOOD EDUCATION 78 12000.0 108000.00 9.00
EIGF-EIGF_NM-EI GROUP SESSION BY NONMED PROF 98 8852.00 221300.00 25.00
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 60 2110.00 52750.00 25.00
EIIF-EIIF_NM-EI INDIVIDUAL SESSION BY NONMED PROF 80 349.25 12032.50 34.45
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 45 459.00 22070.00 48.08
OCCT-97530-OT SESSION BY LICENSED OT 59 343.00 23282.84 67.88
PHY-97110-PT SESSION BY LICENSED PT 69 252.25 17122.73 67.88
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 122 490.75 33312.11 67.88
SPL-92508-GROUP SPL SESSION PER CHILD 38 62.50 825.00 13.20
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 2 102.00 51.00 0.50
VISN-EIIF_NM-EI VISION SERVICES, IND NONMED 5 32.00 1600.00 50.00
Subtotal (Total Children Is Unduplicated) 357 25055.3 492446.18 19.65
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Total 25104.75 494528.68 19.70
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Number of Children (Unduplicated) With at Least One Service 394
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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
53 108.75 5437.50 0.00
Other 0 0.00 0.00 0.00
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Total 53 108.75 5437.50 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
770 11561.25 319883.24 0.00
Other 0 0.00 0.00 0.00
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Total 770 11561.25 319883.24 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
15 11576.25 320715.74 0.00
Other 0 0.00 0.00 0.00
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Total 15 11576.25 320715.74 0.00
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 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 11577.00 320766.65 0.00
Other 0 0.00 0.00 0.00
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Total 1 11577.00 320766.65 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 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
152 11934.50 331831.65 0.00
Other 0 0.00 0.00 0.00
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Total 152 11934.50 331831.65 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 0.00 0.00 0.00
T 0 0.00 0.00 0.00
567 25104.75 494528.68 0.00
Other 0 0.00 0.00 0.00
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Total 567 25104.75 494528.68 0.00