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
Payclass Filters:OTHER
Eligibility Filter:Program Patients
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
CASE-CASE-NON-TCM CASE MANAGEMENT 1 0.500000 18.5000 37.0000
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 1 1.000000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 159 220.750000 8167.7500 37.0000
Subtotal (Total Children Is Unduplicated) 159 222.250000 8186.2500 36.8335
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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 9 16.500000 1237.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 2 4.000000 300.0000 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 7 13.000000 721.5000 55.5000
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
SCREEN-T1023-INTERDISCIPLINARY SCREENING 2 2.000000 100.0000 50.0000
SPCH-92506-SPEECH EVAL BY LICENSED SLP 2 2.000000 97.0000 48.5000
Subtotal (Total Children Is Unduplicated) 29 57.500000 3531.5000 61.4174
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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 14 21.250000 1062.5000 50.0000
INTR-INTR-INTERPRETER 1 2.000000 100.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 14 43.250000 2935.8100 67.8800
OCCT-97530HM-OT SESSION BY OT ASST 1 1.500000 81.4800 54.3200
PHY-97110-PT SESSION BY LICENSED PT 17 29.250000 1985.4900 67.8800
PHY-97110HM-PT SESSION BY PT ASST 1 3.500000 190.1200 54.3200
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 12 43.750000 2969.7500 67.8800
SPL-92508-GROUP SPL SESSION PER CHILD 4 28.000000 369.6000 13.2000
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 59 3572.000000 1786.0000 0.5000
VISN-EIIF_NM-EI VISION SERVICES, IND NONMED 25 362.500000 18125.0000 50.0000
Subtotal (Total Children Is Unduplicated) 190 4856.750000 52202.5300 10.7484
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Total 5136.500000 63920.2800 12.4443
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Number of Children (Unduplicated) With at Least One Service 371
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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 02
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 37.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 1 1.000000 37.0000 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 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
67 51.000000 1887.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 67 51.000000 1887.0000 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 29 59.000000 3904.5800 0.0000
T 0 0.000000 0.0000 0.0000
49 1007.750000 3517.3800 0.0000
Other 2 4.000000 261.0000 0.0000
---------------------------------------------------------
Total 80 1070.750000 7682.9600 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
249 187.000000 7434.3000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 249 187.000000 7434.3000 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
62 1702.000000 2367.4400 0.0000
Other 11 229.000000 685.1600 685.1600
---------------------------------------------------------
Total 73 1931.000000 3052.6000 685.1600