CMS/EIP Fiscal Report Statewide
Services beginning 04/01/2010 ending 06/30/2010 Date of Report:08/18/2010 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 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 360 1021.00 37693.75 36.92
TCON-TCON-TRANSITION CONFERENCE 2 2.00 0.00 0.00
Subtotal (Total Children Is Unduplicated) 365 1031.25 37888.00 36.74
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Screening, Eval, and Assessment,Class #02
EVAL-EVAL-DEVELOPMENTAL EVALUATION 5 9.50 712.50 75.00
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-IPDEI_NM-INITIAL PSYCH & DEV EVAL BY NON-MED PR 3 6.00 333.00 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 70 76.00 5700.00 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 1 1.50 112.50 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 5 8.00 600.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 36 55.00 3052.50 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 26 36.50 3171.00 86.88
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 27 27.00 4995.00 185.00
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 1 1.00 105.00 105.00
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 5 5.00 242.50 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 2 2.00 97.00 48.50
SPCH-92506-SPEECH EVAL BY LICENSED SLP 2 2.00 97.00 48.50
Subtotal (Total Children Is Unduplicated) 154 234.50 19593.00 83.55
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 1 5.00 2253.82 450.76
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 1 0.25 12.50 50.00
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 21 20.50 1025.00 50.00
CONIP-CONIP-CONSULT, ITDS, PHONE 2 2.00 50.00 25.00
CONPF-CONPF-CONSULT, PT, FACE TO FACE 1 0.25 12.50 50.00
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 15 15.50 775.00 50.00
ECE-ECE-EARLY CHILDHOOD EDUCATION 6 375.00 3375.00 9.00
EIGF-EIGF_NM-EI GROUP SESSION BY NONMED PROF 76 992.00 24800.00 25.00
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 49 338.00 8450.00 25.00
EIIF-EIIF_NM-EI INDIVIDUAL SESSION BY NONMED PROF 38 163.50 8175.00 50.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 44 187.00 9350.00 50.00
HERN-EIIF_NM-EI HEARING SERVICES AFTER SHINE NONMED 5 130.00 6500.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 11 34.50 2341.86 67.88
PHY-97110-PT SESSION BY LICENSED PT 8 30.00 2036.40 67.88
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 19 57.50 3903.10 67.88
SPL-92508-GROUP SPL SESSION PER CHILD 11 260.00 3432.00 13.20
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 64 4597.00 2299.70 0.50
VISN-EIIF_NM-EI VISION SERVICES, IND NONMED 15 73.25 3662.50 50.00
Subtotal (Total Children Is Unduplicated) 329 7281.25 82454.38 11.32
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Total 8547.00 139935.38 16.37
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Number of Children (Unduplicated) With at Least One Service 830
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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
56 228.50 11828.82 0.00
Other 0 0.00 0.00 0.00
-------------------------------------------------
Total 56 228.50 11828.82 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
138 1241.50 35458.94 0.00
Other 0 0.00 0.00 0.00
-------------------------------------------------
Total 138 1241.50 35458.94 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 146 276.00 8058.50 6660.00
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
111 158.50 6950.00 0.00
Other 0 0.00 0.00 0.00
-------------------------------------------------
Total 257 434.50 15008.50 6660.00
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 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
130 260.00 3432.00 0.00
Other 0 0.00 0.00 0.00
-------------------------------------------------
Total 130 260.00 3432.00 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
19 52.00 1326.03 0.00
Other 0 0.00 0.00 0.00
-------------------------------------------------
Total 19 52.00 1326.03 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
711 603.25 22320.25 0.00
Other 0 0.00 0.00 0.00
-------------------------------------------------
Total 711 603.25 22320.25 0.00
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 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
25 152.50 7988.54 0.00
Other 0 0.00 0.00 0.00
-------------------------------------------------
Total 25 152.50 7988.54 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 23 48.00 3282.47 0.00
T 0 0.00 0.00 0.00
76 1116.75 3954.81 0.00
Other 0 0.00 0.00 0.00
-------------------------------------------------
Total 100 1165.00 7246.53 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
111 155.50 3727.88 0.00
Other 0 0.00 0.00 0.00
-------------------------------------------------
Total 111 155.50 3727.88 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
237 176.00 6868.79 0.00
Other 0 0.00 0.00 0.00
-------------------------------------------------
Total 237 176.00 6868.79 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 1 3.00 2.70 2.70
H 0 0.00 0.00 0.00
T 2 1.50 75.00 75.00
363 3111.50 21605.46 0.00
Other 54 962.25 3045.94 3045.94
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Total 420 4078.25 24729.10 3123.64