CMS/EIP Fiscal Report Statewide
Services beginning 10/01/2016 ending 12/31/2016 Date of Report:02/04/2017 Page: 1
List order: No List
Payclass Filters:OTHER
Eligibility Filter:Part C (excluding not eligible)
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 43 43.750000 0.0000 0.0000
Subtotal (Total Children Is Unduplicated) 43 43.750000 0.0000 0.0000
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Screening, Eval, and Assessment,Class #02
EXIT-EXIT-EXIT ASSESSMENT 1 2.000000 100.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 1 2.000000 150.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 5 9.000000 675.0000 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 4 7.000000 525.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 4 5.500000 412.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 4 6.000000 450.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 6 10.000000 555.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 16 20.500000 1537.5000 75.0000
NUTR-97803-NUTRITIONAL EVAL, FOLLOW-UP 34 93.000000 4650.0000 50.0000
Subtotal (Total Children Is Unduplicated) 66 156.500000 9138.2500 58.3914
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 44 57.500000 2875.0000 50.0000
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 12 11.500000 287.5000 25.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 53 75.250000 3762.5000 50.0000
CONIP-CONIP-CONSULT, ITDS PHONE 28 49.000000 1225.0000 25.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 6 5.500000 275.0000 50.0000
CONOP-CONOP-CONSULT, OT, PHONE 7 9.000000 225.0000 25.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 27 34.750000 1737.5000 50.0000
CONPP-CONPP-CONSULT, PT, PHONE 9 19.000000 475.0000 25.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 26 38.500000 1925.0000 50.0000
CONSP-CONSP-CONSULT, SLP, PHONE 10 17.000000 425.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 127 585.250000 28918.5200 49.4123
INTR-T1013-INTERPRETER 2 26.000000 1224.0000 47.0769
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 29 154.000000 508.0600 3.2991
OCCT-97530-OT SESSION BY LICENSED OT 41 243.250000 17312.0300 71.1697
OCCT-97530HM-OT SESSION BY OT ASST 3 36.000000 2059.2000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 56 234.000000 16635.1600 71.0904
PHY-97110HM-PT SESSION BY PT ASST 1 12.000000 685.9200 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 142 791.000000 56165.5800 71.0058
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 1 1.000000 57.2000 57.2000
TRAV-TRAVS-Travel by mile 543 35872.00000 15827.4300 0.4412
Subtotal (Total Children Is Unduplicated) 665 38271.50000 152605.6000 3.9874
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Total 38471.750000 161743.8500 4.2042
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Number of Children (Unduplicated) With at Least One Service 711
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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
2 2.000000 100.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 2 2.000000 100.0000 0.0000
Center 05
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 3 48.000000 198.6900 198.6900
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 3 48.000000 198.6900 198.6900
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
3 5.000000 311.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 3 5.000000 311.0000 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 2029 37030.000000 143745.8800 143745.8800
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
98 1164.000000 6927.8000 0.0000
Other 2 4.000000 300.0000 0.0000
---------------------------------------------------------
Total 2129 38198.000000 150973.6800 143745.8800
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 1 5.500000 275.0000 94.8200
27 49.000000 1708.9000 479.9600
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 28 54.500000 1983.9000 574.7800
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
7 7.000000 350.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 7 7.000000 350.0000 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
96 96.000000 6174.2400 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 96 96.000000 6174.2400 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 38 61.250000 1652.3400 1652.3400
---------------------------------------------------------
Total 38 61.250000 1652.3400 1652.3400