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: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 24 16.500000 610.5000 37.0000
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 3 3.000000 0.0000 0.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 1 0.500000 18.5000 37.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 140 362.750000 13412.5000 36.9745
Subtotal (Total Children Is Unduplicated) 162 382.750000 14041.5000 36.6858
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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 3 5.000000 375.0000 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 3 4.000000 222.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 11 18.500000 1387.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 6 11.000000 825.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 1 2.000000 150.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 20 32.500000 1803.7500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 6 13.500000 1012.5000 75.0000
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 33 33.000000 6105.0000 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
SCREEN-T1023-INTERDISCIPLINARY SCREENING 1 2.000000 100.0000 50.0000
VISF-VISF-VISION EVALUATION FUNCTIONAL 1 0.750000 37.5000 50.0000
Subtotal (Total Children Is Unduplicated) 84 137.250000 13029.2500 94.9308
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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 78 6486.000000 20145.0000 3.1059
VISN-EIIF_NM-EI VISION SERVICES, IND NONMED 20 121.250000 6062.5000 50.0000
Subtotal (Total Children Is Unduplicated) 328 11452.00000 155919.8300 13.6151
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Total 11972.000000 182990.5800 15.2849
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Number of Children (Unduplicated) With at Least One Service 560
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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
231 4173.750000 110061.6700 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 231 4173.750000 110061.6700 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 140 140.250000 7128.5000 7128.5000
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 198 196.500000 9941.0000 7128.5000
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
25 25.000000 1508.6400 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 25 25.000000 1508.6400 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
126 107.250000 4110.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 126 107.250000 4110.0000 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 20 34.000000 2317.5000 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 144 4561.750000 8000.4200 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 4 34.750000 227.7500 0.0000
---------------------------------------------------------
Total 20 93.750000 988.1300 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
154 125.250000 5122.8600 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 154 125.250000 5122.8600 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
255 1612.500000 28842.0000 22156.0000
Other 33 611.500000 2271.6200 2271.6200
---------------------------------------------------------
Total 291 2375.500000 31272.5600 24566.5600