CMS/EIP Fiscal Report Statewide
Services beginning 04/01/2012 ending 06/30/2012 Date of Report:08/16/2012 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
EXIT-EXIT-TRANSITION ASSESSMENT 4 8.500000 425.0000 50.0000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 1 2.000000 150.0000 75.0000
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 3 3.000000 145.5000 48.5000
PSTH-97001-EVAL BY LICENSED PT, INITIAL 5 5.000000 242.5000 48.5000
Subtotal (Total Children Is Unduplicated) 13 18.500000 963.0000 52.0541
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 1 1.000000 709.2800 709.2800
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 2 1.500000 75.0000 50.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 3 3.000000 150.0000 50.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 2 0.750000 37.5000 50.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 11 30.750000 1537.5000 50.0000
EIGF-EIGF_NM-EI GROUP SESSION BY NONMED PROF 8 320.000000 8000.0000 25.0000
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 37 302.000000 7550.0000 25.0000
EIIF-EIIF_NM-EI INDIVIDUAL SESSION BY NONMED PROF 14 90.750000 4537.5000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 7 19.000000 950.0000 50.0000
INTR-INTR-INTERPRETER 1 2.000000 100.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 11 34.000000 2307.9200 67.8800
OCCT-97530HM-OT SESSION BY OT ASST 1 1.500000 81.4800 54.3200
PHY-97110-PT SESSION BY LICENSED PT 11 18.000000 1221.8400 67.8800
PHY-97110HM-PT SESSION BY PT ASST 1 3.500000 190.1200 54.3200
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 9 35.500000 2409.7400 67.8800
SPL-92508-GROUP SPL SESSION PER CHILD 4 28.000000 369.6000 13.2000
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 52 3485.000000 1742.5000 0.5000
VISN-EIIF_NM-EI VISION SERVICES, IND NONMED 25 362.500000 18125.0000 50.0000
Subtotal (Total Children Is Unduplicated) 169 4738.750000 50094.9800 10.5713
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Total 4757.250000 51057.9800 10.7327
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Number of Children (Unduplicated) With at Least One Service 176
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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
94 441.000000 22050.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 94 441.000000 22050.0000 0.0000
Center 03
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
12 128.000000 361.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 12 128.000000 361.0000 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
40 566.500000 14312.5800 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 40 566.500000 14312.5800 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
14 28.000000 369.6000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 14 28.000000 369.6000 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
4 14.000000 950.3200 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 4 14.000000 950.3200 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
28 916.500000 3279.6600 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 28 916.500000 3279.6600 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
3 4.000000 250.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 3 4.000000 250.0000 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
99 714.250000 5532.9200 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 99 714.250000 5532.9200 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
18 14.500000 936.8000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 18 14.500000 936.8000 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
61 1701.500000 2329.9400 0.0000
Other 11 229.000000 685.1600 685.1600
---------------------------------------------------------
Total 72 1930.500000 3015.1000 685.1600