CMS/EIP Fiscal Report Statewide
Services beginning 07/01/2012 ending 09/30/2012 Date of Report:11/15/2012 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 1 1.000000 50.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 1 1.500000 112.5000 75.0000
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 1 1.000000 48.5000 48.5000
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 1 1.000000 48.5000 48.5000
SPCH-92506-SPEECH EVAL BY LICENSED SLP 6 6.000000 291.0000 48.5000
Subtotal (Total Children Is Unduplicated) 10 10.500000 550.5000 52.4286
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 7 18.000000 6072.8400 337.3800
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 1 1.000000 50.0000 50.0000
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 14 9.500000 475.0000 50.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 1 1.000000 50.0000 50.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 2 2.000000 100.0000 50.0000
CONPP-CONPP-CONSULT, PT, PHONE 2 1.000000 25.0000 25.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 1 0.500000 25.0000 50.0000
CONSP-CONSP-CONSULT, SLP, PHONE 4 4.000000 100.0000 25.0000
EIGF-EIGF_NM-EI GROUP SESSION BY NONMED PROF 6 376.000000 9400.0000 25.0000
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 37 849.000000 21225.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 15 42.750000 2137.5000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 5 14.500000 984.2600 67.8800
PHY-97110-PT SESSION BY LICENSED PT 10 9.500000 644.8600 67.8800
PHY-97110HM-PT SESSION BY PT ASST 1 1.000000 54.3200 54.3200
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 12 14.493900 983.8500 67.8803
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 37 1822.000000 912.5000 0.5008
VISN-EIIF_NM-EI VISION SERVICES, IND NONMED 21 367.000000 18350.0000 50.0000
Subtotal (Total Children Is Unduplicated) 150 3533.243900 61590.1300 17.4316
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Total 3543.743900 62140.6300 17.5353
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Number of Children (Unduplicated) With at Least One Service 157
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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
51 375.000000 19969.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 51 375.000000 19969.0000 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
6 10.000000 4453.8400 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 6 10.000000 4453.8400 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
69 1070.250000 27674.4100 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 69 1070.250000 27674.4100 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
8 354.000000 177.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 8 354.000000 177.0000 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
1 1.000000 50.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 1 1.000000 50.0000 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 1 0.500000 33.9400 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
101 1190.493900 3979.3200 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 102 1190.993900 4013.2600 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
5 3.500000 224.0200 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 5 3.500000 224.0200 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
17 183.500000 4651.8200 0.0000
Other 23 355.500000 927.2800 927.2800
---------------------------------------------------------
Total 40 539.000000 5579.1000 927.2800