CMS/EIP Fiscal Report Statewide
Services beginning 01/01/2012 ending 03/31/2012 Date of Report:05/15/2012 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 41 21.750000 804.7500 37.0000
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 11 12.000000 0.0000 0.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 8 9.000000 333.0000 37.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 176 392.000000 14504.0000 37.0000
Subtotal (Total Children Is Unduplicated) 178 434.750000 15641.7500 35.9787
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Screening, Eval, and Assessment,Class #02
EVAL-EVAL-DEVELOPMENTAL EVALUATION 2 1.500000 75.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 1 1.000000 75.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 1 1.000000 75.0000 75.0000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 3 3.000000 225.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 7 7.500000 562.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 8 7.000000 388.5000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 6 5.000000 375.0000 75.0000
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 1 1.000000 40.5000 40.5000
MED-99205-OUTPATIENT VISIT, NEW, 60 MINS 1 1.000000 72.7800 72.7800
MED-99214-OUTPATIENT VISIT, EST, 25 MINS 1 1.000000 34.5000 34.5000
MED-99215-OUTPATIENT VISIT, EST, 40 MINS 4 4.000000 200.6000 50.1500
SCREEN-T1023-INTERDISCIPLINARY SCREENING 5 5.000000 250.0000 50.0000
Subtotal (Total Children Is Unduplicated) 20 38.000000 2374.3800 62.4837
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 1 1.000000 50.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 1 8.000000 400.0000 50.0000
INTR-INTR-INTERPRETER 1 0.500000 15.0000 30.0000
TRAN-TRAN-FAMILY TRANSPORTATION 1 1.000000 8.0000 8.0000
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 3 379.000000 189.5000 0.5000
Subtotal (Total Children Is Unduplicated) 5 389.500000 662.5000 1.7009
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Total 862.250000 18678.6300 21.6627
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Number of Children (Unduplicated) With at Least One Service 178
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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 2 1.500000 55.5000 0.0000
P 134 223.750000 5410.5000 5410.5000
D 8 4.750000 232.2500 0.0000
S 0 0.000000 0.0000 0.0000
H 1 1.000000 75.0000 0.0000
T 1 0.500000 15.0000 15.0000
62 41.250000 1564.2500 0.0000
Other 9 9.000000 675.0000 0.0000
---------------------------------------------------------
Total 217 281.750000 8027.5000 5425.5000
Center 04
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 59 27.500000 1036.0000 0.0000
P 120 86.250000 3191.2500 3191.2500
D 6 6.250000 231.2500 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
74 30.500000 1030.5000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 259 150.500000 5489.0000 3191.2500
Center 05
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 103 61.750000 2435.6300 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
23 19.750000 471.7500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 126 81.500000 2907.3800 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 1 2.000000 74.0000 74.0000
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 1 2.000000 74.0000 74.0000
Center 51
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 4 2.000000 74.0000 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
0 0.000000 0.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 4 2.000000 74.0000 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 12 6.000000 222.0000 222.0000
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 3.500000 129.5000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 20 9.500000 351.5000 222.0000
Center 53
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 1 0.250000 9.2500 0.0000
P 5 4.250000 157.2500 157.2500
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 1 55.000000 27.5000 27.5000
T 1 175.000000 87.5000 87.5000
14 76.750000 584.2500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 22 311.250000 865.7500 272.2500
Center 54
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 1 0.250000 9.2500 0.0000
P 1 0.250000 9.2500 9.2500
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 0.250000 9.2500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 3 0.750000 27.7500 9.2500
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 3 4.750000 203.5000 203.5000
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
11 13.000000 464.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 14 17.750000 667.5000 203.5000
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
5 5.250000 194.2500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 5 5.250000 194.2500 0.0000