CMS/EIP Fiscal Report Statewide
Services beginning 01/01/2010 ending 03/31/2010 Date of Report:05/17/2010 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 14 5.50 203.50 37.00
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 4 4.00 0.00 0.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 4 2.50 92.50 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 464 1180.75 43539.75 36.87
Subtotal (Total Children Is Unduplicated) 468 1192.75 43835.75 36.75
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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-IPDEI_NM-INITIAL PSYCH & DEV EVAL BY NON-MED PR 4 7.50 416.25 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 89 116.50 8737.50 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 8 11.50 862.50 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 82 125.50 6965.25 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 11 17.50 1312.50 75.00
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 20 20.00 3700.00 185.00
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 1 1.00 105.00 105.00
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 2 2.00 97.00 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 1 1.00 48.50 48.50
SCREEN-T1023-INTERDISCIPLINARY SCREENING 1 1.00 50.00 50.00
SPCH-92506-SPEECH EVAL BY LICENSED SLP 3 3.00 145.50 48.50
Subtotal (Total Children Is Unduplicated) 155 331.25 24139.75 72.87
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 2 4.00 330.00 82.50
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 4 3.00 150.00 50.00
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 10 9.00 450.00 50.00
CONIP-CONIP-CONSULT, ITDS, PHONE 3 2.25 56.25 25.00
CONOF-CONOF-CONSULT, OT, FACE TO FACE 1 0.50 25.00 50.00
CONPF-CONPF-CONSULT, PT, FACE TO FACE 2 2.50 125.00 50.00
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 18 37.50 1875.00 50.00
CONSP-CONSP-CONSULT, SLP, PHONE 3 2.25 56.25 25.00
ECE-ECE-EARLY CHILDHOOD EDUCATION 3 356.00 3204.00 9.00
EIGF-EIGF_NM-EI GROUP SESSION BY NONMED PROF 3 10.00 250.00 25.00
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 8 92.00 2300.00 25.00
EIIF-EIIF_NM-EI INDIVIDUAL SESSION BY NONMED PROF 34 177.25 8862.50 50.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 28 147.00 7350.00 50.00
HERN-EIIF_NM-EI HEARING SERVICES AFTER SHINE NONMED 10 70.00 3500.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 12 37.00 2511.56 67.88
OCCT-97530HM-OT SESSION BY OT ASST 2 8.50 461.72 54.32
PHY-97110-PT SESSION BY LICENSED PT 13 29.42 1997.34 67.89
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 30 55.50 3603.30 64.92
SPL-92508-GROUP SPL SESSION PER CHILD 11 194.00 2560.80 13.20
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 73 3439.00 1723.50 0.50
VISN-EIIF_NM-EI VISION SERVICES, IND NONMED 16 590.50 29525.00 50.00
Subtotal (Total Children Is Unduplicated) 225 5267.17 70917.22 13.46
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Total 6791.17 138892.72 20.45
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Number of Children (Unduplicated) With at Least One Service 832
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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
116 371.25 16262.50 0.00
Other 0 0.00 0.00 0.00
-------------------------------------------------
Total 116 371.25 16262.50 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
21 392.25 20067.50 0.00
Other 0 0.00 0.00 0.00
-------------------------------------------------
Total 21 392.25 20067.50 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 33 46.50 2136.00 2136.00
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
87 734.25 25788.75 0.00
Other 0 0.00 0.00 0.00
-------------------------------------------------
Total 120 780.75 27924.75 2136.00
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 46.50 2136.00 2136.00
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
99 929.25 28386.55 0.00
Other 0 0.00 0.00 0.00
-------------------------------------------------
Total 99 975.75 30522.55 2136.00
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 46.50 2136.00 2136.00
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
9 948.25 29748.85 0.00
Other 0 0.00 0.00 0.00
-------------------------------------------------
Total 9 994.75 31884.85 2136.00
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 46.50 2136.00 2136.00
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
950 1770.50 61312.60 0.00
Other 0 0.00 0.00 0.00
-------------------------------------------------
Total 950 1817.00 63448.60 2136.00
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 46.50 2136.00 2136.00
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
43 1863.00 66301.14 0.00
Other 0 0.00 0.00 0.00
-------------------------------------------------
Total 43 1909.50 68437.14 2136.00
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 46.50 2136.00 2136.00
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
105 3345.17 97108.65 0.00
Other 0 0.00 0.00 0.00
-------------------------------------------------
Total 115 3409.92 100483.46 2136.00
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 46.50 2136.00 2136.00
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
136 3470.42 101755.90 0.00
Other 0 0.00 0.00 0.00
-------------------------------------------------
Total 136 3535.17 105130.71 2136.00
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 46.50 2136.00 2136.00
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
134 3609.42 106723.15 0.00
Other 0 0.00 0.00 0.00
-------------------------------------------------
Total 134 3674.17 110097.96 2136.00
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 46.50 2136.00 2136.00
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
416 6544.92 133123.25 0.00
Other 37 161.50 2380.66 2380.66
-------------------------------------------------
Total 454 6791.17 138892.72 4530.66