CMS/EIP Fiscal Report Statewide
Services beginning 10/01/2017 ending 12/31/2017 Date of Report:02/03/2018 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
TCM-T1017TL-TARGETED CASE MANAGEMENT 88 139.250000 5152.2500 37.0000
Subtotal (Total Children Is Unduplicated) 88 139.250000 5152.2500 37.0000
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Screening, Eval, and Assessment,Class #02
AUDE-V5010-ASSESSMENT FOR HEARING AID 1 1.000000 45.0000 45.0000
AUDE-V5090-DISPENSING FEE PER HEARING AID 1 1.000000 115.0000 115.0000
EXIT-EXIT-EXIT ASSESSMENT 13 26.000000 1300.0000 50.0000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 10 14.000000 953.6200 68.1157
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 16 24.500000 1837.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 7 12.000000 900.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 23 39.500000 2192.2500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 11 17.500000 1312.5000 75.0000
NUTR-97803-NUTRITIONAL EVAL, FOLLOW-UP 16 61.000000 3050.0000 50.0000
OCTF-97168-OT RE-EVAL EST PLAN CARE 2 2.000000 102.1000 51.0500
OCTH-97167-OT EVAL HIGH COMPLEXITY 4 4.000000 204.2000 51.0500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 1 1.000000 51.0500 51.0500
SPCH-92524-BEHAV & QUAL ANALYSIS OF
VOICE AND RES 1 1.000000 51.0500 51.0500
Subtotal (Total Children Is Unduplicated) 89 204.500000 12114.2700 59.2385
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 17 27.000000 1350.0000 50.0000
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 3 1.750000 43.7500 25.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 8 9.000000 450.0000 50.0000
CONIP-CONIP-CONSULT, ITDS PHONE 2 1.500000 37.5000 25.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 7 7.000000 350.0000 50.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 3 2.750000 137.5000 50.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 15 14.500000 725.0000 50.0000
CONSP-CONSP-CONSULT, SLP, PHONE 1 0.500000 12.5000 25.0000
DSTT-DSTT-DIRECT SERVICE COORDINATOR TRAVEL 126 175.500000 35.7200 0.2035
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 146 558.500000 27925.0000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 52 154.000000 1540.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 25 74.750000 5269.5200 70.4953
OCCT-97530HM-OT SESSION BY OT ASST 4 27.000000 1544.4000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 28 120.000000 8363.9100 69.6993
PHY-97110HM-PT SESSION BY PT ASST 10 24.000000 1371.8400 57.1600
SENS-V5050-IN EAR MONAURAL HEARING AID 1 1.000000 228.0000 228.0000
SENS-V5264-EARMOLD 1 1.000000 18.0000 18.0000
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 118 503.250000 34924.3000 69.3975
TRAV-TRAVS-Travel by mile 543 28404.00000 12571.2300 0.4426
Subtotal (Total Children Is Unduplicated) 744 30107.00000 96898.1700 3.2185
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Total 30450.750000 114164.6900 3.7492
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Number of Children (Unduplicated) With at Least One Service 877
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Center 03
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
1 1.000000 50.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 1 1.000000 50.0000 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 1765 29168.000000 93293.3200 93293.3200
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
35 774.250000 1692.7300 0.0000
Other 3 4.000000 270.7500 0.0000
---------------------------------------------------------
Total 1803 29946.250000 95256.8000 93293.3200
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 4 22.000000 139.9000 124.9000
35 39.750000 2046.3700 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 39 61.750000 2186.2700 124.9000
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
149 112.500000 4162.5000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 149 112.500000 4162.5000 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
133 118.250000 7694.9100 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 133 118.250000 7694.9100 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
0 0.000000 0.0000 0.0000
Other 101 211.000000 4814.2100 4854.2100
---------------------------------------------------------
Total 101 211.000000 4814.2100 4854.2100