CMS/EIP Fiscal Report Statewide
Services beginning 01/01/2012 ending 03/31/2012 Date of Report:05/16/2012 Page: 1
List order: No List
Payclass Filters:OTHER
Eligibility Filter:Program Patients
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 31 69.250000 2562.2500 37.0000
Subtotal (Total Children Is Unduplicated) 31 69.250000 2562.2500 37.0000
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 1 2.000000 150.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 4 8.000000 444.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 5 9.500000 712.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 2 3.500000 262.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 12 22.000000 1221.0000 55.5000
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 2 2.000000 97.0000 48.5000
PSTH-97001-EVAL BY LICENSED PT, INITIAL 2 2.000000 97.0000 48.5000
SCREEN-T1023-INTERDISCIPLINARY SCREENING 1 1.000000 50.0000 50.0000
Subtotal (Total Children Is Unduplicated) 23 50.000000 3034.0000 60.6800
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EI Services,Class #03
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 2 2.000000 100.0000 50.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 2 1.250000 62.5000 50.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 27 34.000000 1700.0000 50.0000
CONSP-CONSP-CONSULT, SLP, PHONE 1 1.000000 25.0000 25.0000
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 1 8.000000 200.0000 25.0000
EIIF-96154-HEALTH AND BEHAVIOR INTERVENTION 1 120.000000 5700.0000 47.5000
EIIF-EIIF_NM-EI INDIVIDUAL SESSION BY NONMED PROF 10 46.750000 2337.5000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 20 31.500000 1575.0000 50.0000
INTR-INTR-INTERPRETER 2 5.000000 100.0000 20.0000
OCCT-97530-OT SESSION BY LICENSED OT 8 34.500000 2341.8600 67.8800
PHY-97110-PT SESSION BY LICENSED PT 9 14.500000 984.2600 67.8800
PHY-97110HM-PT SESSION BY PT ASST 1 3.000000 162.9600 54.3200
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 14 43.500000 2952.7800 67.8800
SPL-92508-GROUP SPL SESSION PER CHILD 17 248.750000 3283.5000 13.2000
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 125 12157.00000 6146.5000 0.5056
VISN-EIIF_NM-EI VISION SERVICES, IND NONMED 28 293.500000 14675.0000 50.0000
Subtotal (Total Children Is Unduplicated) 209 13044.25000 42346.8600 3.2464
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Total 13163.500000 47943.1100 3.6421
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Number of Children (Unduplicated) With at Least One Service 260
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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
81 339.000000 16725.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 81 339.000000 16725.0000 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
5 16.000000 1086.0800 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 5 16.000000 1086.0800 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
124 248.000000 3273.6000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 124 248.000000 3273.6000 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
102 67.750000 2506.7500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 102 67.750000 2506.7500 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 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 8.000000 523.6600 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 3 8.000000 523.6600 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 43 69.500000 4400.4100 0.0000
T 0 0.000000 0.0000 0.0000
156 7538.000000 12775.8400 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 199 7607.500000 17176.2500 0.0000
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
62 1992.000000 3462.9000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 62 1992.000000 3462.9000 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
13 10.000000 638.1200 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 13 10.000000 638.1200 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 1 2.000000 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
80 2535.250000 1381.2500 0.0000
Other 34 338.000000 1058.5000 1058.5000
---------------------------------------------------------
Total 115 2875.250000 2550.7500 1169.5000