CMS/EIP Fiscal Report Statewide
Services beginning 01/01/2010 ending 03/31/2010 Date of Report:05/17/2010 Page: 1
Payclass Filters:TPIN
Eligibility Filter:Not Part C
List order: No List
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 4 5.75 212.75 37.00
Subtotal (Total Children Is Unduplicated) 4 5.75 212.75 37.00
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Screening, Eval, and Assessment,Class #02
EVAL-EVAL-DEVELOPMENTAL EVALUATION 1 4.00 200.00 50.00
EXIT-EXIT-TRANSITION ASSESSMENT 1 1.50 75.00 50.00
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 12 19.50 1462.50 75.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 4 6.00 450.00 75.00
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 3 5.00 375.00 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 2 3.50 262.50 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 6 10.50 582.75 55.50
IPDEI-IPDEI_NM-INITIAL PSYCH & DEV EVAL BY NON-MED PR 3 4.98 614.32 123.36
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 168 229.51 17253.88 75.18
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 61 90.09 6757.05 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 46 62.83 4712.25 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 120 177.00 10316.67 58.29
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 77 105.59 9689.33 91.76
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 2 2.00 370.00 185.00
Subtotal (Total Children Is Unduplicated) 264 722.00 53121.25 73.58
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 1 2.00 100.00 50.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 2 13.50 675.00 50.00
Subtotal (Total Children Is Unduplicated) 3 15.50 775.00 50.00
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Total 743.25 54109.00 72.80
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Number of Children (Unduplicated) With at Least One Service 266
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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 36 43.50 2589.75 0.00
S 0 0.00 0.00 0.00
H 3 6.00 400.00 0.00
T 0 0.00 0.00 0.00
4 4.25 157.25 0.00
Other 80 107.50 7594.50 0.00
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Total 123 161.25 10741.50 0.00
Center 02
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 43.50 2589.75 0.00
S 0 0.00 0.00 0.00
H 0 6.00 400.00 0.00
T 0 0.00 0.00 0.00
1 6.25 307.25 0.00
Other 0 107.50 7594.50 0.00
-------------------------------------------------
Total 1 163.25 10891.50 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 4 4.00 481.00 799.62
D 0 43.50 2589.75 0.00
S 0 0.00 0.00 0.00
H 0 6.00 400.00 0.00
T 0 0.00 0.00 0.00
0 6.25 307.25 0.00
Other 0 107.50 7594.50 0.00
-------------------------------------------------
Total 4 167.25 11372.50 799.62
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 4.00 481.00 799.62
D 0 43.50 2589.75 0.00
S 0 0.00 0.00 0.00
H 0 6.00 400.00 0.00
T 0 0.00 0.00 0.00
4 14.26 794.99 0.00
Other 0 107.50 7594.50 0.00
-------------------------------------------------
Total 4 175.26 11860.24 799.62
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 4.00 481.00 799.62
D 0 43.50 2589.75 0.00
S 0 0.00 0.00 0.00
H 0 6.00 400.00 0.00
T 0 0.00 0.00 0.00
37 61.26 4290.74 0.00
Other 0 107.50 7594.50 0.00
-------------------------------------------------
Total 37 222.26 15355.99 799.62
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 4.00 481.00 799.62
D 0 43.50 2589.75 0.00
S 0 0.00 0.00 0.00
H 0 6.00 400.00 0.00
T 0 0.00 0.00 0.00
1 63.26 4440.74 0.00
Other 0 107.50 7594.50 0.00
-------------------------------------------------
Total 1 224.26 15505.99 799.62
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 4.00 481.00 799.62
D 0 43.50 2589.75 0.00
S 0 0.00 0.00 0.00
H 0 6.00 400.00 0.00
T 0 0.00 0.00 0.00
88 163.76 11656.49 0.00
Other 0 107.50 7594.50 0.00
-------------------------------------------------
Total 88 324.76 22721.74 799.62
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 4.00 481.00 799.62
D 0 43.50 2589.75 0.00
S 0 0.00 0.00 0.00
H 0 6.00 400.00 0.00
T 0 0.00 0.00 0.00
137 395.76 27554.99 0.00
Other 0 107.50 7594.50 0.00
-------------------------------------------------
Total 137 556.76 38620.24 799.62
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 4.00 481.00 799.62
D 0 43.50 2589.75 0.00
S 0 0.00 0.00 0.00
H 0 6.00 400.00 0.00
T 0 0.00 0.00 0.00
2 398.76 27779.99 0.00
Other 0 107.50 7594.50 0.00
-------------------------------------------------
Total 2 559.76 38845.24 799.62
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 4.00 481.00 799.62
D 0 43.50 2589.75 0.00
S 0 0.00 0.00 0.00
H 5 14.50 998.50 0.00
T 0 0.00 0.00 0.00
31 440.59 30546.74 0.00
Other 0 107.50 7594.50 0.00
-------------------------------------------------
Total 36 610.09 42210.49 799.62
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 3 7.66 727.14 1045.76
D 0 43.50 2589.75 0.00
S 0 0.00 0.00 0.00
H 0 14.50 998.50 0.00
T 0 0.00 0.00 0.00
8 455.09 32675.86 0.00
Other 0 107.50 7594.50 0.00
-------------------------------------------------
Total 11 628.25 44585.75 1045.76
Center 54
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 7.66 727.14 1045.76
D 0 43.50 2589.75 0.00
S 0 0.00 0.00 0.00
H 0 14.50 998.50 0.00
T 0 0.00 0.00 0.00
49 520.59 37049.11 0.00
Other 0 107.50 7594.50 0.00
-------------------------------------------------
Total 49 693.75 48959.00 1045.76
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 1 9.16 977.14 1208.26
D 0 43.50 2589.75 0.00
S 0 0.00 0.00 0.00
H 8 22.50 2998.50 0.00
T 0 0.00 0.00 0.00
27 560.59 39949.11 0.00
Other 0 107.50 7594.50 0.00
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Total 36 743.25 54109.00 1208.26