CMS/EIP Fiscal Report Statewide
Services beginning 07/01/2010 ending 09/30/2010 Date of Report:11/17/2010 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 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
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 4 8.000000 444.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 4 9.500000 712.5000 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 1 1.000000 48.5000 48.5000
Subtotal (Total Children Is Unduplicated) 36 66.000000 6472.0000 98.0606
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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 3 1.500000 75.0000 50.0000
ECE-ECE-EARLY CHILDHOOD EDUCATION 2 14.000000 175.0000 12.5000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 10 4.750000 237.5000 50.0000
INTR-INTR-INTERPRETER 1 2.000000 100.0000 50.0000
PHY-97110-PT SESSION BY LICENSED PT 1 0.500000 33.9400 67.8800
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 1 0.500000 33.9400 67.8800
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 2 104.000000 52.0000 0.5000
Subtotal (Total Children Is Unduplicated) 20 129.750000 1152.3800 8.8815
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Total 542.250000 20324.6300 37.4820
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Number of Children (Unduplicated) With at Least One Service 197
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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
19 19.000000 3195.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 19 19.000000 3195.0000 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
22 18.000000 1044.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 22 18.000000 1044.0000 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 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
32 119.000000 1109.1300 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 40 133.500000 2131.1300 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
0 0.000000 0.0000 0.0000
Other 2 4.250000 194.2500 0.0000
---------------------------------------------------------
Total 2 4.250000 194.2500 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
127 94.250000 3478.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 127 94.250000 3478.0000 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 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
179 183.000000 6923.0000 175.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 179 183.000000 6923.0000 175.0000