CMS/EIP Fiscal Report Statewide
Services beginning 04/01/2010 ending 06/30/2010 Date of Report:08/18/2010 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 11 3.75 138.75 37.00
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 3 3.00 0.00 0.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 2 1.50 55.50 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 309 881.25 32523.00 36.91
TCON-TCON-TRANSITION CONFERENCE 2 2.00 0.00 0.00
Subtotal (Total Children Is Unduplicated) 314 891.50 32717.25 36.70
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 2 2.00 150.00 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 2 3.00 225.00 75.00
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 59 63.50 4762.50 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 4 6.00 450.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 32 48.50 2691.75 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 15 23.50 1848.00 78.64
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 18 18.00 3330.00 185.00
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 1 1.00 105.00 105.00
Subtotal (Total Children Is Unduplicated) 104 165.50 13562.25 81.95
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 1 0.25 12.50 50.00
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 1 0.25 12.50 50.00
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 1 1.00 25.00 25.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 14 9.75 487.50 50.00
PHY-97110-PT SESSION BY LICENSED PT 5 14.75 1001.23 67.88
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 6 21.00 1425.48 67.88
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 5 158.00 79.00 0.50
Subtotal (Total Children Is Unduplicated) 33 205.00 3043.21 14.84
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Total 1262.00 49322.71 39.08
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Number of Children (Unduplicated) With at Least One Service 444
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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
19 19.00 3435.00 0.00
Other 0 0.00 0.00 0.00
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Total 19 19.00 3435.00 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
12 15.00 1135.50 0.00
Other 0 0.00 0.00 0.00
-------------------------------------------------
Total 12 15.00 1135.50 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
17 46.00 918.75 0.00
Other 0 0.00 0.00 0.00
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Total 17 46.00 918.75 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
664 532.75 19711.75 0.00
Other 0 0.00 0.00 0.00
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Total 664 532.75 19711.75 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 1 0.25 9.25 0.00
H 21 44.50 3019.97 0.00
T 0 0.00 0.00 0.00
27 102.00 701.49 0.00
Other 0 0.00 0.00 0.00
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Total 49 146.75 3730.71 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 0.00 0.00 0.00
T 0 0.00 0.00 0.00
86 77.00 2800.00 0.00
Other 0 0.00 0.00 0.00
-------------------------------------------------
Total 86 77.00 2800.00 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 0.00 0.00 0.00
T 0 0.00 0.00 0.00
200 135.75 4939.50 0.00
Other 0 0.00 0.00 0.00
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Total 200 135.75 4939.50 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 0.00 0.00 0.00
T 0 0.00 0.00 0.00
230 289.75 12651.50 0.00
Other 0 0.00 0.00 0.00
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Total 230 289.75 12651.50 0.00