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:Program Patients
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 7 5.25 194.25 37.00
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 6 6.00 0.00 0.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 1 1.00 37.00 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 283 517.75 19156.75 37.00
Subtotal (Total Children Is Unduplicated) 291 530.00 19388.00 36.58
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 7 11.00 825.00 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 5 7.50 416.25 55.50
IPDEI-IPDEI_NM-INITIAL PSYCH & DEV EVAL BY NON-MED PR 4 4.00 222.00 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 80 103.50 7762.50 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 12 16.50 1237.50 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 71 106.00 5877.50 55.45
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 16 31.50 2362.50 75.00
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 28 28.00 5180.00 185.00
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
SCREEN-T1023-INTERDISCIPLINARY SCREENING 3 3.00 150.00 50.00
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) 170 324.00 24866.75 76.75
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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 6936.51 89075.39 12.84
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Number of Children (Unduplicated) With at Least One Service 687
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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
29 185.00 12260.00 0.00
Other 0 0.00 0.00 0.00
-------------------------------------------------
Total 29 185.00 12260.00 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 56 122.00 6040.00 6040.00
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
100 877.00 21815.75 0.00
Other 0 0.00 0.00 0.00
-------------------------------------------------
Total 156 999.00 27855.75 6040.00
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 0 122.00 6040.00 6040.00
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
3 878.75 21895.94 0.00
Other 0 0.00 0.00 0.00
-------------------------------------------------
Total 3 1000.75 27935.94 6040.00
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 0 122.00 6040.00 6040.00
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
18 901.75 23320.74 0.00
Other 0 0.00 0.00 0.00
-------------------------------------------------
Total 18 1023.75 29360.74 6040.00
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 0 122.00 6040.00 6040.00
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
493 1325.00 41336.93 0.00
Other 0 0.00 0.00 0.00
-------------------------------------------------
Total 493 1447.00 47376.93 6040.00
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 0 122.00 6040.00 6040.00
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
44 1484.00 46383.13 0.00
Other 0 0.00 0.00 0.00
-------------------------------------------------
Total 44 1606.00 52423.13 6040.00
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 0 122.00 6040.00 6040.00
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
132 3157.26 51299.95 0.00
Other 0 0.00 0.00 0.00
-------------------------------------------------
Total 158 3330.01 60758.87 6040.00
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 0 122.00 6040.00 6040.00
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
178 3334.51 56684.70 0.00
Other 1 2.00 111.00 83.25
-------------------------------------------------
Total 179 3509.26 66254.62 6123.25
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 0 122.00 6040.00 6040.00
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
13 3347.76 57174.95 0.00
Other 0 2.00 111.00 83.25
-------------------------------------------------
Total 13 3522.51 66744.87 6123.25
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 0 122.00 6040.00 6040.00
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 2 5.00 250.00 250.00
268 6446.26 75694.19 0.00
Other 86 312.50 3672.28 3644.53
-------------------------------------------------
Total 356 6936.51 89075.39 9934.53