CMS/EIP Fiscal Report Statewide
Services beginning 07/01/2017 ending 09/30/2017 Date of Report:11/05/2017 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
Screening, Eval, and Assessment,Class #02
EXIT-EXIT-EXIT ASSESSMENT 1 2.000000 100.0000 50.0000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 10 15.000000 1125.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 7 9.500000 712.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 6 9.000000 675.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 12 18.500000 1026.7500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 5 8.000000 600.0000 75.0000
NUTR-97803-NUTRITIONAL EVAL, FOLLOW-UP 18 53.000000 2650.0000 50.0000
OCTH-97166-OT EVAL MODERATE COMPLEXITY 1 1.000000 51.0500 51.0500
OCTH-97167-OT EVAL HIGH COMPLEXITY 1 1.000000 51.0500 51.0500
PSTH-97163-PT EVAL HIGH COMPLEXITY 1 1.000000 51.0500 51.0500
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) 49 121.000000 7195.5500 59.4674
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 31 42.500000 2125.0000 50.0000
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 5 5.250000 131.2500 25.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 13 14.000000 700.0000 50.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 5 4.500000 225.0000 50.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 10 9.250000 462.5000 50.0000
DSTT-DSTT-DIRECT SERVICE COORDINATOR TRAVEL 159 195.750000 0.0000 0.0000
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 37 685.000000 17125.0000 25.0000
EIIF-EIIF_NM-EI INDIVIDUAL SESSION BY NONMED PROF 1 3.000000 150.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 230 1108.750000 55437.5000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 19 44.000000 440.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 19 65.500000 4608.7000 70.3618
OCCT-97530HM-OT SESSION BY OT ASST 5 24.000000 1372.8000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 36 169.500000 11995.0800 70.7674
PHY-97110HM-PT SESSION BY PT ASST 2 3.250000 185.7700 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 144 754.000000 51423.8700 68.2014
SPL-92508-GROUP SPL SESSION PER CHILD 1 4.000000 55.5200 13.8800
TRAV-TRAVS-Travel by mile 875 52833.00000 23369.4000 0.4423
Subtotal (Total Children Is Unduplicated) 1085 55965.25000 169807.3900 3.0342
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Total 56086.250000 177002.9400 3.1559
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Number of Children (Unduplicated) With at Least One Service 1106
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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
51 578.000000 14450.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 51 578.000000 14450.0000 0.0000
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
2 4.000000 261.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 2 4.000000 261.0000 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 2757 51524.250000 141126.5200 141126.5200
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
110 3312.000000 5713.9100 0.0000
Other 3 3.250000 225.0000 0.0000
---------------------------------------------------------
Total 2870 54839.500000 147065.4300 141126.5200
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 2 41.000000 67.8000 52.8000
54 365.750000 4080.7900 2108.8200
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 56 406.750000 4148.5900 2161.6200
Center 53
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 1 1.000000 71.4400 0.0000
---------------------------------------------------------
Total 1 1.000000 71.4400 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
117 114.500000 7154.3600 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 117 114.500000 7154.3600 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
13 109.000000 2777.1000 2777.1000
Other 25 33.500000 1075.0200 1075.0200
---------------------------------------------------------
Total 38 142.500000 3852.1200 3852.1200