CMS/EIP Fiscal Report Statewide
Services beginning 01/01/2010 ending 03/31/2010 Date of Report:05/17/2010 Page: 1
Eligibility Filter:DEI Only
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 147 83.00 3071.00 37.00
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 60 64.00 0.00 0.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 75 69.25 2562.25 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 459 1248.75 46194.50 36.99
Subtotal (Total Children Is Unduplicated) 466 1465.00 51827.75 35.38
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Screening, Eval, and Assessment,Class #02
ASTE-ASTE-ASSISTIVE TECHNOLOGY EVAL 1 1.00 48.50 48.50
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 1 1.00 8.83 8.83
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 1 1.00 10.80 10.80
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 1 1.00 21.79 21.79
EVAL-EVAL-DEVELOPMENTAL EVALUATION 15 12.00 600.00 50.00
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 4 5.00 375.00 75.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 2.00 150.00 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 3 4.00 300.00 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 1 1.50 83.25 55.50
IPDEI-IPDEI_NM-INITIAL PSYCH & DEV EVAL BY NON-MED PR 3 5.50 305.25 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 23 26.50 1987.50 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 3 4.50 337.50 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 22 18.00 1350.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 20 23.50 1304.25 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 28 28.00 2100.00 75.00
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 3 3.00 555.00 185.00
MED-99205-OUTPATIENT VISIT, NEW, 60 MINS 4 4.00 291.12 72.78
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 1 1.00 105.00 105.00
MED-99215-OUTPATIENT VISIT, EST, 40 MINS 6 6.00 300.90 50.15
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 1 1.00 48.50 48.50
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 1 1.00 48.50 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 1 1.00 48.50 48.50
SCREEN-T1023-INTERDISCIPLINARY SCREENING 9 9.00 450.00 50.00
SPCH-92506-SPEECH EVAL BY LICENSED SLP 4 4.00 194.00 48.50
Subtotal (Total Children Is Unduplicated) 82 164.50 11024.19 67.02
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 5 7.00 350.00 50.00
COIFP-COIFP-IFSP CONSULT, PRO, BY PHONE 1 1.75 43.75 25.00
CONPF-CONPF-CONSULT, PT, FACE TO FACE 1 0.25 12.50 50.00
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 1 3.25 162.50 50.00
EIGF-EIGF_NM-EI GROUP SESSION BY NONMED PROF 1 28.00 700.00 25.00
EIIF-96154-HEALTH AND BEHAVIOR INTERVENTION 1 12.00 600.00 50.00
EIIF-EIIF_NM-EI INDIVIDUAL SESSION BY NONMED PROF 2 12.00 600.00 50.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 27 195.00 9750.00 50.00
HERN-T1027SC-EI HEARING SERVICES AFTER SHINE 1 6.00 300.00 50.00
INTR-INTR-INTERPRETER 5 17.00 918.00 54.00
OCCT-97530-OT SESSION BY LICENSED OT 4 26.75 1815.79 67.88
PHY-97110-PT SESSION BY LICENSED PT 5 17.00 1153.96 67.88
PHY-97110HM-PT SESSION BY PT ASST 1 4.50 244.44 54.32
SHIN-T1027SC-INITIAL SHINE SERVICES, INDIVIDUAL 1 3.00 150.00 50.00
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 3 17.75 1204.87 67.88
SPL-92508-GROUP SPL SESSION PER CHILD 1 4.00 52.80 13.20
TRAN-TRAN-FAMILY TRANSPORTATION 10 10.00 80.00 8.00
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 42 9332.00 4817.60 0.52
Subtotal (Total Children Is Unduplicated) 56 9697.25 22956.21 2.37
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Total 11326.75 85808.15 7.58
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Number of Children (Unduplicated) With at Least One Service 476
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Center 01
Flag Claims Units Chgs Paid
-------------------------------------------------
R 13 7.75 286.75 0.00
U 0 0.00 0.00 0.00
B 123 86.25 3220.00 0.00
P 345 2323.00 10254.00 10254.00
D 16 13.75 802.50 0.00
S 43 30.25 1119.25 0.00
H 1 1.00 75.00 0.00
T 32 1408.50 1372.50 1372.50
318 295.00 10427.91 0.00
Other 76 444.00 5193.93 0.00
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Total 967 4609.50 32751.84 11626.50
Center 04
Flag Claims Units Chgs Paid
-------------------------------------------------
R 0 7.75 286.75 0.00
U 0 0.00 0.00 0.00
B 302 289.50 10834.75 0.00
P 28 2515.00 11089.75 11089.75
D 0 13.75 802.50 0.00
S 0 30.25 1119.25 0.00
H 4 15.00 792.88 717.88
T 0 1408.50 1372.50 1372.50
432 556.00 19536.91 0.00
Other 0 444.00 5193.93 0.00
-------------------------------------------------
Total 766 5279.75 51029.22 13180.13
Center 05
Flag Claims Units Chgs Paid
-------------------------------------------------
R 0 7.75 286.75 0.00
U 0 0.00 0.00 0.00
B 282 431.50 16116.50 0.00
P 0 2515.00 11089.75 11089.75
D 0 13.75 802.50 0.00
S 0 30.25 1119.25 0.00
H 0 15.00 792.88 717.88
T 0 1408.50 1372.50 1372.50
133 894.50 22589.93 0.00
Other 0 444.00 5193.93 0.00
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Total 415 5760.25 59363.99 13180.13
Center 06
Flag Claims Units Chgs Paid
-------------------------------------------------
R 0 7.75 286.75 0.00
U 0 0.00 0.00 0.00
B 85 485.25 18105.25 101.75
P 226 3159.25 16376.32 16376.32
D 0 13.75 802.50 0.00
S 0 30.25 1119.25 0.00
H 0 15.00 792.88 717.88
T 0 1408.50 1372.50 1372.50
272 2188.75 30632.50 55.50
Other 0 444.00 5193.93 0.00
-------------------------------------------------
Total 583 7752.50 74681.88 18623.95
Center 07
Flag Claims Units Chgs Paid
-------------------------------------------------
R 0 7.75 286.75 0.00
U 0 0.00 0.00 0.00
B 0 485.25 18105.25 101.75
P 3 3161.50 16459.57 16459.57
D 0 13.75 802.50 0.00
S 0 30.25 1119.25 0.00
H 0 15.00 792.88 717.88
T 0 1408.50 1372.50 1372.50
0 2188.75 30632.50 55.50
Other 0 444.00 5193.93 0.00
-------------------------------------------------
Total 3 7754.75 74765.13 18707.20
Center 10
Flag Claims Units Chgs Paid
-------------------------------------------------
R 0 7.75 286.75 0.00
U 0 0.00 0.00 0.00
B 0 485.25 18105.25 101.75
P 3 3165.75 16616.82 16616.82
D 0 13.75 802.50 0.00
S 0 30.25 1119.25 0.00
H 0 15.00 792.88 717.88
T 0 1408.50 1372.50 1372.50
2 2191.25 30790.75 55.50
Other 0 444.00 5193.93 0.00
-------------------------------------------------
Total 5 7761.50 75080.63 18864.45
Center 51
Flag Claims Units Chgs Paid
-------------------------------------------------
R 0 7.75 286.75 0.00
U 0 0.00 0.00 0.00
B 14 493.25 18401.25 101.75
P 17 3501.25 18489.74 18489.74
D 0 13.75 802.50 0.00
S 0 30.25 1119.25 0.00
H 0 15.00 792.88 717.88
T 0 1408.50 1372.50 1372.50
13 2199.00 31077.50 55.50
Other 0 444.00 5193.93 0.00
-------------------------------------------------
Total 44 8112.75 77536.30 20737.37
Center 52
Flag Claims Units Chgs Paid
-------------------------------------------------
R 0 7.75 286.75 0.00
U 0 0.00 0.00 0.00
B 2 494.00 18429.00 101.75
P 0 3501.25 18489.74 18489.74
D 0 13.75 802.50 0.00
S 0 30.25 1119.25 0.00
H 0 15.00 792.88 717.88
T 0 1408.50 1372.50 1372.50
3 2199.75 31105.25 55.50
Other 0 444.00 5193.93 0.00
-------------------------------------------------
Total 5 8114.25 77591.80 20737.37
Center 53
Flag Claims Units Chgs Paid
-------------------------------------------------
R 0 7.75 286.75 0.00
U 0 0.00 0.00 0.00
B 8 505.25 19036.25 101.75
P 12 3511.50 19016.74 19016.74
D 0 13.75 802.50 0.00
S 0 30.25 1119.25 0.00
H 13 635.00 1422.88 1347.88
T 7 1896.50 1765.00 1765.00
70 3634.75 34342.00 55.50
Other 0 444.00 5193.93 0.00
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Total 110 10678.75 82985.30 22286.87
Center 54
Flag Claims Units Chgs Paid
-------------------------------------------------
R 0 7.75 286.75 0.00
U 0 0.00 0.00 0.00
B 27 523.75 19850.75 101.75
P 6 3882.00 19297.49 19297.49
D 0 13.75 802.50 0.00
S 0 30.25 1119.25 0.00
H 0 635.00 1422.88 1347.88
T 0 1896.50 1765.00 1765.00
17 3764.00 34730.05 55.50
Other 0 444.00 5193.93 0.00
-------------------------------------------------
Total 50 11197.00 84468.60 22567.62
Center 55
Flag Claims Units Chgs Paid
-------------------------------------------------
R 0 7.75 286.75 0.00
U 0 0.00 0.00 0.00
B 0 523.75 19850.75 101.75
P 6 3892.00 19742.49 19742.49
D 0 13.75 802.50 0.00
S 0 30.25 1119.25 0.00
H 0 635.00 1422.88 1347.88
T 13 2001.56 2227.02 2227.02
14 3778.69 35162.58 55.50
Other 0 444.00 5193.93 0.00
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Total 33 11326.75 85808.15 23474.64