CMS/EIP Fiscal Report Statewide
Services beginning 01/01/2016 ending 03/31/2016 Date of Report:05/12/2016 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
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 16 11.750000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 9 18.250000 675.2500 37.0000
Subtotal (Total Children Is Unduplicated) 25 30.000000 675.2500 22.5083
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Screening, Eval, and Assessment,Class #02
AUDE-92585-AUD EVOKED RESPONSE (COMP) 1 1.000000 65.1400 65.1400
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 9 14.000000 1050.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 5 6.500000 487.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 3 5.000000 375.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 9 14.000000 777.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 4 4.500000 337.5000 75.0000
NUTR-97803-NUTRITIONAL EVAL, FOLLOW-UP 12 52.000000 2600.0000 50.0000
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 2 2.000000 102.1000 51.0500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 1 1.000000 51.0500 51.0500
Subtotal (Total Children Is Unduplicated) 30 100.000000 5845.2900 58.4529
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 26 30.750000 1537.5000 50.0000
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 9 7.500000 187.5000 25.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 61 62.500000 3125.0000 50.0000
CONIP-CONIP-CONSULT, ITDS PHONE 25 37.750000 943.7500 25.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 1 1.000000 50.0000 50.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 3 3.000000 150.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 93 359.000000 17920.0000 49.9164
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 20 39.000000 390.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 21 86.500000 6179.5600 71.4400
OCCT-97530HM-OT SESSION BY OT ASST 2 15.000000 858.0000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 46 214.750000 15341.7400 71.4400
PHY-97110HM-PT SESSION BY PT ASST 3 4.500000 257.2200 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 157 690.500000 49282.2600 71.3718
SPL-92508-GROUP SPL SESSION PER CHILD 1 2.000000 104.8800 52.4400
TRAV-TRAVS-Travel by mile 419 20970.00000 9295.1000 0.4433
Subtotal (Total Children Is Unduplicated) 504 22523.75000 105622.5100 4.6894
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Total 22653.750000 112143.0500 4.9503
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Number of Children (Unduplicated) With at Least One Service 524
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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
1 1.000000 71.4400 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 1 1.000000 71.4400 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 1094 19427.000000 77714.7100 77714.7100
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
187 2978.250000 21732.3700 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 1281 22405.250000 99447.0800 77714.7100
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 6 32.000000 132.4700 132.4700
3 15.000000 1050.1600 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 9 47.000000 1182.6300 132.4700
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
5 4.250000 196.2500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 5 4.250000 196.2500 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
138 136.000000 9424.7300 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 138 136.000000 9424.7300 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
0 0.000000 0.0000 0.0000
Other 35 60.250000 1820.9200 1820.9200
---------------------------------------------------------
Total 35 60.250000 1820.9200 1820.9200