CMS/EIP Fiscal Report Statewide
Services beginning 07/01/2010 ending 09/30/2010 Date of Report:11/17/2010 Page: 1
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 22 16.000000 592.0000 37.0000
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 3 3.000000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 126 327.500000 12108.2500 36.9718
Subtotal (Total Children Is Unduplicated) 145 346.500000 12700.2500 36.6530
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Screening, Eval, and Assessment,Class #02
EVAL-EVAL-DEVELOPMENTAL EVALUATION 2 3.000000 150.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 2 3.000000 225.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 2.000000 150.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 2 2.000000 111.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 6 11.000000 825.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 5 9.500000 712.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 10 17.000000 943.5000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 5 11.500000 862.5000 75.0000
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 15 15.000000 2775.0000 185.0000
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 4 4.000000 420.0000 105.0000
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 1 1.000000 48.5000 48.5000
PSTH-97001-EVAL BY LICENSED PT, INITIAL 5 5.000000 242.5000 48.5000
VISF-VISF-VISION EVALUATION FUNCTIONAL 1 0.750000 37.5000 50.0000
Subtotal (Total Children Is Unduplicated) 50 84.750000 7503.0000 88.5310
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 2 2.000000 420.0000 210.0000
COIFP-COIFP-IFSP CONSULT, PRO, BY PHONE 1 0.500000 25.0000 50.0000
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 10 8.000000 400.0000 50.0000
CONIP-CONIP-CONSULT, ITDS, PHONE 1 0.250000 6.2500 25.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 13 16.500000 825.0000 50.0000
ECE-ECE-EARLY CHILDHOOD EDUCATION 6 98.000000 1141.0000 11.6429
EIGF-EIGF_NM-EI GROUP SESSION BY NONMED PROF 93 3430.000000 85750.0000 25.0000
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 45 865.000000 21625.0000 25.0000
EIIF-EIIF_NM-EI INDIVIDUAL SESSION BY NONMED PROF 25 86.500000 4325.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 56 189.000000 9450.0000 50.0000
INTR-INTR-INTERPRETER 1 2.000000 100.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 6 20.500000 1391.5400 67.8800
PHY-97110-PT SESSION BY LICENSED PT 9 12.250000 831.5300 67.8800
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 16 34.250000 2324.8900 67.8800
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 1 1.000000 54.3200 54.3200
SPL-92508-GROUP SPL SESSION PER CHILD 5 79.000000 1042.8000 13.2000
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 77 6456.000000 20130.0000 3.1180
VISN-EIIF_NM-EI VISION SERVICES, IND NONMED 20 121.250000 6062.5000 50.0000
Subtotal (Total Children Is Unduplicated) 327 11422.00000 155904.8300 13.6495
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Total 11853.250000 176108.0800 14.8574
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Number of Children (Unduplicated) With at Least One Service 509
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Center 01
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 0 0.000000 0.0000 0.0000
P 0 0.000000 0.0000 0.0000
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
63 218.250000 9837.5000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 63 218.250000 9837.5000 0.0000
Center 02
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 0 0.000000 0.0000 0.0000
P 0 0.000000 0.0000 0.0000
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
1 2.000000 100.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 1 2.000000 100.0000 0.0000
Center 04
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 0 0.000000 0.0000 0.0000
P 0 0.000000 0.0000 0.0000
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
213 4155.750000 106731.6700 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 213 4155.750000 106731.6700 0.0000
Center 05
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 0 0.000000 0.0000 0.0000
P 138 137.250000 6962.0000 6962.0000
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
58 56.250000 2812.5000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 196 193.500000 9774.5000 6962.0000
Center 06
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 0 0.000000 0.0000 0.0000
P 0 0.000000 0.0000 0.0000
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
39 78.000000 1029.6000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 39 78.000000 1029.6000 0.0000
Center 07
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 0 0.000000 0.0000 0.0000
P 0 0.000000 0.0000 0.0000
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
23 21.000000 1247.6400 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 23 21.000000 1247.6400 0.0000
Center 09
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 0 0.000000 0.0000 0.0000
P 0 0.000000 0.0000 0.0000
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
115 90.250000 3359.2500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 115 90.250000 3359.2500 0.0000
Center 51
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 0 0.000000 0.0000 0.0000
P 0 0.000000 0.0000 0.0000
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
5 15.000000 1018.2000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 5 15.000000 1018.2000 0.0000
Center 52
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 0 0.000000 0.0000 0.0000
P 0 0.000000 0.0000 0.0000
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 8 14.500000 1022.0000 0.0000
T 0 0.000000 0.0000 0.0000
124 4527.750000 5682.9200 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 132 4542.250000 6704.9200 0.0000
Center 53
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 0 0.000000 0.0000 0.0000
P 0 0.000000 0.0000 0.0000
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
16 59.000000 760.3800 0.0000
Other 2 4.250000 194.2500 0.0000
---------------------------------------------------------
Total 18 63.250000 954.6300 0.0000
Center 55
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 0 0.000000 0.0000 0.0000
P 0 0.000000 0.0000 0.0000
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
146 111.000000 4595.6100 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 146 111.000000 4595.6100 0.0000
Center 57
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 0 0.000000 0.0000 0.0000
P 0 0.000000 0.0000 0.0000
D 0 0.000000 0.0000 0.0000
S 3 151.500000 158.9400 138.9400
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
248 1600.000000 28324.0000 22156.0000
Other 33 611.500000 2271.6200 2271.6200
---------------------------------------------------------
Total 284 2363.000000 30754.5600 24566.5600