CMS/EIP Fiscal Report Statewide
Services beginning 04/01/2017 ending 06/30/2017 Date of Report:08/05/2017 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 137 151.750000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 57 143.250000 5189.2500 36.2251
Subtotal (Total Children Is Unduplicated) 194 295.000000 5189.2500 17.5907
-----------------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 6 8.500000 637.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 2 2.500000 187.5000 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 6 9.000000 499.5000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 1 1.500000 112.5000 75.0000
OCTH-97165-OT EVAL LOW COMPLEXITY 1 1.000000 51.0500 51.0500
PSTF-97164-PT RE-EVAL EST PLAN CARE 2 2.000000 102.1000 51.0500
PSTH-97163-PT EVAL HIGH COMPLEXITY 1 1.000000 51.0500 51.0500
SCREEN-T1023-SCREENING 1 2.000000 100.0000 50.0000
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 2 2.000000 102.1000 51.0500
SPCH-92524-BEHAV & QUAL ANALYSIS OF
VOICE AND RES 1 1.000000 51.0500 51.0500
Subtotal (Total Children Is Unduplicated) 19 32.000000 2006.8500 62.7141
-----------------------------------------------------------------------------------------------------------------------
EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 15 21.750000 1087.5000 50.0000
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 1 1.000000 25.0000 25.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 9 10.000000 500.0000 50.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 11 9.750000 487.5000 50.0000
CONOP-CONOP-CONSULT, OT, PHONE 1 0.500000 12.5000 25.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 6 6.000000 300.0000 50.0000
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 28 224.000000 5600.0000 25.0000
EIIF-EIIF_NM-EI INDIVIDUAL SESSION BY NONMED PROF 2 14.500000 725.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 65 270.500000 13525.0000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 32 148.000000 1480.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 6 18.000000 1285.9200 71.4400
OCCT-97530HM-OT SESSION BY OT ASST 4 37.000000 2116.4000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 13 48.500000 3315.9100 68.3693
PHY-97110HM-PT SESSION BY PT ASST 2 15.000000 857.4000 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 43 250.750000 17733.5800 70.7222
TRAV-TRAVS-Travel by mile 149 8329.000000 3681.4800 0.4420
Subtotal (Total Children Is Unduplicated) 276 9404.250000 52733.1900 5.6074
-----------------------------------------------------------------------------------------------------------------------
Total 9731.250000 59929.2900 6.1584
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 455
-----------------------------------------------------------------------------------------------------------------------
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
29 234.000000 6100.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 29 234.000000 6100.0000 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 707 4770.000000 19232.6900 19232.6900
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
260 3126.250000 12579.1000 0.0000
Other 2 3.000000 225.0000 0.0000
---------------------------------------------------------
Total 969 7899.250000 32036.7900 19232.6900
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 3 100.000000 181.8300 181.8300
129 1261.000000 11926.3300 10016.6000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 132 1361.000000 12108.1600 10198.4300
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 32.250000 168.7100 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 5 32.250000 168.7100 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
116 111.500000 6990.5800 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 116 111.500000 6990.5800 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
23 25.750000 952.7500 0.0000
Other 36 67.500000 1572.3000 1572.3000
---------------------------------------------------------
Total 59 93.250000 2525.0500 1572.3000