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
Agency Filter:EXT
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 2 3.500000 262.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 5 7.500000 562.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 1 2.000000 111.0000 55.5000
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) 30 74.000000 3992.3000 53.9500
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 30 41.500000 2075.0000 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 9 9.000000 450.0000 50.0000
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 217 1062.000000 53100.0000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 19 44.000000 440.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 16 60.500000 4251.5000 70.2727
OCCT-97530HM-OT SESSION BY OT ASST 5 24.000000 1372.8000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 35 164.500000 11637.8800 70.7470
PHY-97110HM-PT SESSION BY PT ASST 2 3.250000 185.7700 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 129 701.000000 47637.5500 67.9566
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) 974 55658.50000 162906.6700 2.9269
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Total 55732.500000 166898.9700 2.9946
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Number of Children (Unduplicated) With at Least One Service 982
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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 2187 51189.750000 132251.2700 132251.2700
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
104 3306.000000 5285.2700 0.0000
Other 2 3.000000 225.0000 0.0000
---------------------------------------------------------
Total 2293 54498.750000 137761.5400 132251.2700
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 40.000000 17.8000 17.8000
39 354.750000 3402.1500 2098.8200
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 40 394.750000 3419.9500 2116.6200
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