CMS/EIP Fiscal Report Statewide
Services beginning 01/01/2010 ending 03/31/2010 Date of Report:05/17/2010 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 10 3.75 138.75 37.00
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 4 4.00 0.00 0.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 3 2.00 74.00 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 393 1027.25 37934.25 36.93
Subtotal (Total Children Is Unduplicated) 397 1037.00 38147.00 36.79
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Screening, Eval, and Assessment,Class #02
EXIT-EXIT-TRANSITION ASSESSMENT 6 2.75 137.50 50.00
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 7 10.50 787.50 75.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 1.00 75.00 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 3 4.50 249.75 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 79 103.50 7762.50 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 3 6.00 450.00 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 5 7.50 562.50 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 71 106.50 5910.75 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 9 15.00 1125.00 75.00
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 16 16.00 2960.00 185.00
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 1 1.00 105.00 105.00
SCREEN-T1023-INTERDISCIPLINARY SCREENING 1 1.00 50.00 50.00
Subtotal (Total Children Is Unduplicated) 127 275.25 20175.50 73.30
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 1 2.00 30.00 15.00
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 2 1.00 50.00 50.00
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 2 1.00 50.00 50.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 10 10.00 500.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 3 8.50 576.98 67.88
PHY-97110-PT SESSION BY LICENSED PT 4 4.75 322.43 67.88
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 6 8.75 593.95 67.88
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 4 193.00 100.50 0.52
Subtotal (Total Children Is Unduplicated) 28 229.00 2223.86 9.71
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Total 1541.25 60546.36 39.28
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Number of Children (Unduplicated) With at Least One Service 547
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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
17 17.00 3065.00 0.00
Other 0 0.00 0.00 0.00
-------------------------------------------------
Total 17 17.00 3065.00 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
10 151.00 3975.00 0.00
Other 0 0.00 0.00 0.00
-------------------------------------------------
Total 10 151.00 3975.00 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
2 155.00 4236.00 0.00
Other 0 0.00 0.00 0.00
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Total 2 155.00 4236.00 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
863 883.00 32236.50 0.00
Other 0 0.00 0.00 0.00
-------------------------------------------------
Total 863 883.00 32236.50 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 10 18.25 1238.81 0.00
T 0 0.00 0.00 0.00
30 952.75 33064.55 0.00
Other 0 0.00 0.00 0.00
-------------------------------------------------
Total 40 971.00 34303.36 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 18.25 1238.81 0.00
T 0 0.00 0.00 0.00
113 1058.00 36958.80 0.00
Other 0 0.00 0.00 0.00
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Total 113 1076.25 38197.61 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 18.25 1238.81 0.00
T 0 0.00 0.00 0.00
107 1160.00 40631.05 0.00
Other 0 0.00 0.00 0.00
-------------------------------------------------
Total 107 1178.25 41869.86 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 18.25 1238.81 0.00
T 1 20.00 14.00 14.00
311 1503.00 59293.55 0.00
Other 0 0.00 0.00 0.00
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Total 312 1541.25 60546.36 14.00