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:EIP DEI DEIP
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
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 8 11.500000 862.5000 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 1 1.500000 112.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 11 16.500000 915.7500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 5 8.000000 600.0000 75.0000
Subtotal (Total Children Is Unduplicated) 20 47.000000 3203.2500 68.1543
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 1 1.000000 50.0000 50.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 1 0.250000 12.5000 50.0000
DSTT-DSTT-DIRECT SERVICE COORDINATOR TRAVEL 159 195.750000 0.0000 0.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 13 46.750000 2337.5000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 3 5.000000 357.2000 71.4400
PHY-97110-PT SESSION BY LICENSED PT 1 5.000000 357.2000 71.4400
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 15 53.000000 3786.3200 71.4400
Subtotal (Total Children Is Unduplicated) 174 306.750000 6900.7200 22.4962
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Total 353.750000 10103.9700 28.5625
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Number of Children (Unduplicated) With at Least One Service 194
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Center 09
Flag Claims Units Chgs Paid
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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 570 334.500000 8875.2500 8875.2500
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
6 6.000000 428.6400 0.0000
Other 1 0.250000 0.0000 0.0000
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Total 577 340.750000 9303.8900 8875.2500
Center 52
Flag Claims Units Chgs Paid
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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 1.000000 50.0000 35.0000
15 11.000000 678.6400 10.0000
Other 0 0.000000 0.0000 0.0000
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Total 16 12.000000 728.6400 45.0000
Center 53
Flag Claims Units Chgs Paid
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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
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Total 1 1.000000 71.4400 0.0000