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:LEA
Eligibility Filter:Program Patients
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Screening, Eval, and Assessment,Class #02
EVAL-EVAL-DEVELOPMENTAL EVALUATION 2 2.500000 125.0000 50.0000
IPDEF-IPDEF_NM-F/U PSYCH & DEV EVAL BY NON-MED PROF 6 12.000000 422.0000 35.1667
IPDEI-IPDEI_NM-INITIAL PSYCH & DEV EVAL BY NON-MED PR 19 33.500000 1088.5000 32.4925
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 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) 28 50.000000 1732.5000 34.6500
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EI Services,Class #03
ECE-ECE-EARLY CHILDHOOD EDUCATION 118 18560.00000 18560.0000 1.0000
EIGF-EIGF_NM-EI GROUP SESSION BY NONMED PROF 40 3872.000000 96800.0000 25.0000
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 104 3005.000000 75125.0000 25.0000
EIIF-EIIF_NM-EI INDIVIDUAL SESSION BY NONMED PROF 9 83.500000 4175.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 15 218.000000 10900.0000 50.0000
HERN-T1027SC-EI HEARING SERVICES AFTER SHINE 8 28.500000 1425.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 104 476.000000 32310.8800 67.8800
PHY-97110-PT SESSION BY LICENSED PT 89 388.250000 26354.4100 67.8800
PHY-97110HM-PT SESSION BY PT ASST 1 2.000000 108.6400 54.3200
SHIN-T1027SC-INITIAL SHINE SERVICES, INDIVIDUAL 2 3.000000 150.0000 50.0000
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 104 471.500000 32005.4200 67.8800
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 1 2.000000 108.6400 54.3200
SPL-92508-GROUP SPL SESSION PER CHILD 17 23.000000 303.6000 13.2000
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 1 38.000000 19.0000 0.5000
VISN-EIIF_NM-EI VISION SERVICES, IND NONMED 18 144.000000 7200.0000 50.0000
Subtotal (Total Children Is Unduplicated) 322 27314.75000 305545.5900 11.1861
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Total 27364.750000 307278.0900 11.2290
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Number of Children (Unduplicated) With at Least One Service 348
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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
47 144.000000 7200.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 47 144.000000 7200.0000 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
774 7349.250000 211534.4300 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 774 7349.250000 211534.4300 0.0000
Center 10
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
20 47.000000 2555.3200 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 20 47.000000 2555.3200 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
50 129.000000 5685.5000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 50 129.000000 5685.5000 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
641 19695.500000 80302.8400 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 641 19695.500000 80302.8400 0.0000