CMS/EIP Fiscal Report Statewide
Services beginning 01/01/2017 ending 03/31/2017 Date of Report:05/05/2017 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 59 73.000000 71.4400 0.9786
TCM-T1017TL-TARGETED CASE MANAGEMENT 4 4.000000 148.0000 37.0000
Subtotal (Total Children Is Unduplicated) 63 77.000000 219.4400 2.8499
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Screening, Eval, and Assessment,Class #02
EVAL-96111-DEVELOPMENTAL EVALUATION 1 1.000000 50.0000 50.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 1.500000 112.5000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 0.500000 37.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 1 1.500000 112.5000 75.0000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 6 9.000000 675.0000 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 2 2.500000 187.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 6 9.500000 527.2500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 3 4.500000 337.5000 75.0000
NUTR-97802-NUTRITIONAL EVAL, INITIAL 1 2.000000 100.0000 50.0000
NUTR-97803-NUTRITIONAL EVAL, FOLLOW-UP 21 103.000000 5150.0000 50.0000
OCTF-97168-OT RE-EVAL EST PLAN CARE 1 1.000000 51.0500 51.0500
OCTH-97166-OT EVAL MODERATE COMPLEXITY 2 2.000000 102.1000 51.0500
OCTH-97167-OT EVAL HIGH COMPLEXITY 1 1.000000 51.0500 51.0500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 1 1.000000 51.0500 51.0500
Subtotal (Total Children Is Unduplicated) 41 145.500000 7957.5000 54.6907
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 35 47.250000 2362.5000 50.0000
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 8 8.750000 218.7500 25.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 20 40.750000 2037.5000 50.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 7 7.000000 350.0000 50.0000
CONOP-CONOP-CONSULT, OT, PHONE 1 0.500000 12.5000 25.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 18 27.250000 1362.5000 50.0000
CONPP-CONPP-CONSULT, PT, PHONE 5 7.000000 175.0000 25.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 34 43.000000 2150.0000 50.0000
CONSP-CONSP-CONSULT, SLP, PHONE 1 1.000000 25.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 175 790.500000 39525.0000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 20 52.000000 520.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 21 121.000000 8574.6600 70.8650
OCCT-97530HM-OT SESSION BY OT ASST 7 48.000000 2745.6000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 42 173.750000 12219.3800 70.3274
PHY-97110HM-PT SESSION BY PT ASST 3 32.000000 1829.1200 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 175 868.250000 61856.1800 71.2424
TRAV-TRAVS-Travel by mile 688 43531.00000 19275.1500 0.4428
Subtotal (Total Children Is Unduplicated) 794 45799.00000 155238.8400 3.3896
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Total 46021.500000 163415.7800 3.5509
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Number of Children (Unduplicated) With at Least One Service 853
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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 2285 45505.250000 148101.3900 148101.3900
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 0.750000 27.7500 27.7500
11 11.750000 634.5700 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 2297 45517.750000 148763.7100 148129.1400
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 1 0.750000 53.5800 0.0000
T 0 0.000000 0.0000 0.0000
66 286.500000 4740.8100 2520.9800
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 67 287.250000 4794.3900 2520.9800
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 6.500000 337.5000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 7 6.500000 337.5000 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
121 121.000000 7655.1800 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 121 121.000000 7655.1800 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 1 1.000000 50.0000 50.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
0 0.000000 0.0000 0.0000
Other 29 88.000000 1815.0000 1815.0000
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Total 30 89.000000 1865.0000 1865.0000