CMS/EIP Fiscal Report Statewide
Services beginning 07/01/2016 ending 09/30/2016 Date of Report:10/31/2016 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 57 67.750000 25.0000 0.3690
TCM-T1017TL-TARGETED CASE MANAGEMENT 81 172.750000 6336.2500 36.6787
Subtotal (Total Children Is Unduplicated) 135 240.500000 6361.2500 26.4501
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 1.500000 112.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 1 1.500000 83.2500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 10 13.500000 950.0000 70.3704
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 3 4.500000 337.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 1 1.500000 112.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 5 7.500000 363.0000 48.4000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 14 19.500000 1462.5000 75.0000
NUTR-97803-NUTRITIONAL EVAL, FOLLOW-UP 32 109.000000 5450.0000 50.0000
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 4 4.000000 204.2000 51.0500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 1 1.000000 51.0500 51.0500
Subtotal (Total Children Is Unduplicated) 64 163.500000 9126.5000 55.8196
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 52 60.000000 3000.0000 50.0000
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 8 7.500000 187.5000 25.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 85 127.500000 6375.0000 50.0000
CONIP-CONIP-CONSULT, ITDS PHONE 31 65.750000 1643.7500 25.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 8 8.000000 400.0000 50.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 33 46.500000 2325.0000 50.0000
CONPP-CONPP-CONSULT, PT, PHONE 8 12.000000 300.0000 25.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 39 40.500000 2025.0000 50.0000
CONSP-CONSP-CONSULT, SLP, PHONE 14 33.000000 825.0000 25.0000
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 12 230.000000 5750.0000 25.0000
EIIF-EIIF_NM-EI INDIVIDUAL SESSION BY NONMED PROF 2 13.000000 650.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 195 917.750000 45887.5000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 20 32.000000 320.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 75 351.250000 24959.1600 71.0581
OCCT-97530HM-OT SESSION BY OT ASST 7 44.000000 2516.8000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 99 495.000000 35201.7200 71.1146
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 268 1576.500000 112133.5300 71.1282
TRAV-TRAVS-Travel by mile 866 59136.00000 26145.8400 0.4421
Subtotal (Total Children Is Unduplicated) 999 63196.25000 270645.8000 4.2826
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Total 63600.250000 286133.5500 4.4989
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Number of Children (Unduplicated) With at Least One Service 1119
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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 1871 30195.250000 131515.3900 131568.6400
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 1551 32566.500000 120294.7000 120294.7000
215 247.750000 11293.8400 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 3637 63009.500000 263103.9300 251863.3400
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
27 65.750000 2453.2600 1257.8200
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 27 65.750000 2453.2600 1257.8200
Center 53
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 126 100.000000 3938.5000 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 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 126 100.000000 3938.5000 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
16 15.500000 726.2500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 16 15.500000 726.2500 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
126 119.500000 7988.6000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 126 119.500000 7988.6000 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 1 1.000000 10.0000 10.0000
23 231.000000 5787.0000 5750.0000
Other 38 58.000000 2126.0100 2126.0100
---------------------------------------------------------
Total 62 290.000000 7923.0100 7886.0100