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
Agency Filter:EXT
Payclass Filters:OTHER
Eligibility Filter:Part C (excluding not eligible)
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Screening, Eval, and Assessment,Class #02
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 1 1.000000 48.5000 48.5000
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 2 3.000000 145.5000 48.5000
PSTH-97001-EVAL BY LICENSED PT, INITIAL 1 1.000000 48.5000 48.5000
SPCH-92506-SPEECH EVAL BY LICENSED SLP 1 1.000000 48.5000 48.5000
Subtotal (Total Children Is Unduplicated) 5 6.000000 291.0000 48.5000
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EI Services,Class #03
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 2 24.000000 600.0000 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 11 37.500000 1875.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 6 20.750000 1408.5100 67.8800
OCCT-97530HM-OT SESSION BY OT ASST 3 6.000000 325.9200 54.3200
PHY-97110-PT SESSION BY LICENSED PT 2 4.750000 322.4300 67.8800
PHY-97110HM-PT SESSION BY PT ASST 1 3.000000 162.9600 54.3200
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 13 52.750000 3580.6700 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 70 13074.00000 6589.0000 0.5040
VISN-EIIF_NM-EI VISION SERVICES, IND NONMED 25 342.750000 17137.5000 50.0000
Subtotal (Total Children Is Unduplicated) 132 14011.75000 44944.4500 3.2076
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Total 14017.750000 45235.4500 3.2270
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Number of Children (Unduplicated) With at Least One Service 135
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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 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 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 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
103 9960.000000 17123.8600 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 103 9960.000000 17123.8600 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
31 27.000000 1772.7000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 31 27.000000 1772.7000 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
103 3060.500000 3022.5400 0.0000
Other 15 106.750000 1324.4700 1324.4700
---------------------------------------------------------
Total 118 3167.250000 4347.0100 1324.4700