CMS/EIP Fiscal Report Statewide
Services beginning 10/01/2011 ending 12/31/2011 Date of Report:02/15/2012 Page: 1
List order: No List
Eligibility Filter:DEI Only
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
CASE-CASE-NON-TCM CASE MANAGEMENT 37 20.250000 749.2500 37.0000
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 10 10.000000 0.0000 0.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 6 7.750000 286.7500 37.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 179 467.750000 17306.7500 37.0000
Subtotal (Total Children Is Unduplicated) 180 505.750000 18342.7500 36.2684
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Screening, Eval, and Assessment,Class #02
EVAL-EVAL-DEVELOPMENTAL EVALUATION 6 5.500000 275.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 3 3.000000 225.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 2 3.000000 225.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 3 3.500000 194.2500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 15 16.000000 1200.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 1 1.000000 75.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 10 12.000000 666.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 15 17.500000 1312.5000 75.0000
MED-99205-OUTPATIENT VISIT, NEW, 60 MINS 1 1.000000 72.7800 72.7800
MED-99215-OUTPATIENT VISIT, EST, 40 MINS 2 2.000000 100.3000 50.1500
SCREEN-T1023-INTERDISCIPLINARY SCREENING 3 3.000000 150.0000 50.0000
Subtotal (Total Children Is Unduplicated) 32 67.500000 4495.8300 66.6049
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 1 10.000000 500.0000 50.0000
INTR-INTR-INTERPRETER 2 1.250000 27.5000 22.0000
TRAN-TRAN-FAMILY TRANSPORTATION 4 4.000000 32.0000 8.0000
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 11 789.000000 394.5000 0.5000
Subtotal (Total Children Is Unduplicated) 16 804.250000 954.0000 1.1862
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Total 1377.500000 23792.5800 17.2723
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Number of Children (Unduplicated) With at Least One Service 180
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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 43 39.250000 1895.0000 0.0000
P 170 166.250000 5533.0000 5533.0000
D 3 2.250000 83.2500 0.0000
S 0 0.000000 0.0000 0.0000
H 2 2.000000 150.0000 0.0000
T 3 55.000000 27.5000 27.5000
64 51.250000 1971.7500 0.0000
Other 16 16.500000 1237.5000 0.0000
---------------------------------------------------------
Total 301 332.500000 10898.0000 5560.5000
Center 04
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 73 44.750000 1655.7500 0.0000
P 40 20.000000 740.0000 740.0000
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
113 66.000000 2175.5000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 226 130.750000 4571.2500 740.0000
Center 05
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 202 101.750000 3865.8300 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
18 9.250000 231.2500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 220 111.000000 4097.0800 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 4 3.000000 111.0000 0.0000
P 6 3.000000 111.0000 111.0000
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
4 1.000000 37.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 14 7.000000 259.0000 111.0000
Center 51
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 11 8.000000 296.0000 0.0000
P 3 96.000000 122.5000 122.5000
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
7 7.000000 373.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 21 111.000000 791.5000 122.5000
Center 52
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 3 2.000000 74.0000 0.0000
P 20 10.750000 397.7500 397.7500
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 1 2.000000 111.0000 0.0000
T 0 0.000000 0.0000 0.0000
20 47.500000 575.5000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 44 62.250000 1158.2500 397.7500
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 14 117.000000 533.5000 533.5000
D 1 2.000000 150.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 2 175.000000 87.5000 87.5000
T 6 3.250000 83.2500 83.2500
18 273.250000 826.2500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 41 570.500000 1680.5000 704.2500
Center 54
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
8 52.000000 318.5000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 8 52.000000 318.5000 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
1 0.500000 18.5000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 1 0.500000 18.5000 0.0000