CMS/EIP Fiscal Report Statewide
Services beginning 10/01/2011 ending 12/31/2011 Date of Report:02/16/2012 Page: 1
List order: No List
Payclass Filters:OTHER
Eligibility Filter:Part C (excluding not eligible)
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 9 17.250000 638.2500 37.0000
Subtotal (Total Children Is Unduplicated) 9 17.250000 638.2500 37.0000
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Screening, Eval, and Assessment,Class #02
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 9 17.500000 1312.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 2 4.000000 300.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 3 5.000000 375.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 2 3.500000 194.2500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 2 6.000000 450.0000 75.0000
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 1 1.000000 48.5000 48.5000
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 4 5.000000 242.5000 48.5000
PSTH-97001-EVAL BY LICENSED PT, INITIAL 1 1.000000 48.5000 48.5000
SCREEN-T1023-INTERDISCIPLINARY SCREENING 1 1.000000 50.0000 50.0000
SPCH-92506-SPEECH EVAL BY LICENSED SLP 3 3.000000 145.5000 48.5000
Subtotal (Total Children Is Unduplicated) 24 47.000000 3166.7500 67.3777
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 1 1.000000 559.9500 559.9500
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 2 3.000000 150.0000 50.0000
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 1 1.000000 50.0000 50.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 9 11.750000 587.5000 50.0000
ECE-ECE-EARLY CHILDHOOD EDUCATION 1 120.000000 120.0000 1.0000
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 4 31.000000 775.0000 25.0000
EIIF-96154-HEALTH AND BEHAVIOR INTERVENTION 1 195.000000 9165.0000 47.0000
EIIF-EIIF_NM-EI INDIVIDUAL SESSION BY NONMED PROF 6 36.000000 1800.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 27 48.750000 2437.5000 50.0000
INTR-INTR-INTERPRETER 2 12.000000 240.0000 20.0000
OCCT-97530-OT SESSION BY LICENSED OT 13 36.750000 2494.5900 67.8800
OCCT-97530HM-OT SESSION BY OT ASST 3 6.000000 325.9200 54.3200
PHY-97110-PT SESSION BY LICENSED PT 4 6.750000 458.1900 67.8800
PHY-97110HM-PT SESSION BY PT ASST 1 3.000000 162.9600 54.3200
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 18 64.250000 4361.2900 67.8800
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 1 0.500000 27.1600 54.3200
SPL-92508-GROUP SPL SESSION PER CHILD 6 79.000000 1042.8000 13.2000
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 85 13729.00000 7051.0000 0.5136
VISN-EIIF_NM-EI VISION SERVICES, IND NONMED 25 342.750000 17137.5000 50.0000
Subtotal (Total Children Is Unduplicated) 176 14727.50000 48946.3600 3.3235
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Total 14791.750000 52751.3600 3.5663
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Number of Children (Unduplicated) With at Least One Service 203
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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
76 479.500000 19910.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 76 479.500000 19910.0000 0.0000
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
45 84.000000 1436.8800 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 45 84.000000 1436.8800 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
3 6.000000 450.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 3 6.000000 450.0000 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
1 1.000000 50.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 1 1.000000 50.0000 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 9 7.500000 277.5000 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 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 9 7.500000 277.5000 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 38 68.500000 4367.4500 0.0000
T 0 0.000000 0.0000 0.0000
153 10600.000000 18880.2200 0.0000
Other 3 2.250000 134.8500 0.0000
---------------------------------------------------------
Total 194 10670.750000 23382.5200 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
12 299.000000 595.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 12 299.000000 595.0000 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
38 30.750000 1911.4500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 38 30.750000 1911.4500 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
112 3106.500000 3413.5400 0.0000
Other 15 106.750000 1324.4700 1324.4700
---------------------------------------------------------
Total 127 3213.250000 4738.0100 1324.4700