CMS/EIP Fiscal Report Statewide
Services beginning 10/01/2018 ending 12/31/2018 Date of Report:02/06/2019 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 132 94.500000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 552 1219.500000 45121.5000 37.0000
Subtotal (Total Children Is Unduplicated) 552 1314.000000 45121.5000 34.3390
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Screening, Eval, and Assessment,Class #02
EXIT-EXIT-EXIT ASSESSMENT 12 22.000000 1100.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 2 2.500000 187.5000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 1.500000 112.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 2 2.500000 138.7500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 83 135.000000 10125.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 65 108.000000 8100.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 13 22.500000 1687.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 149 245.500000 13625.2500 55.5000
NUTR-97802-NUTRITIONAL EVAL, INITIAL 1 4.000000 200.0000 50.0000
NUTR-97803-NUTRITIONAL EVAL, FOLLOW-UP 4 15.000000 750.0000 50.0000
OCTF-97168-OT RE-EVAL EST PLAN CARE 1 1.000000 51.0500 51.0500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 2 2.000000 102.1000 51.0500
Subtotal (Total Children Is Unduplicated) 184 561.500000 36179.6500 64.4339
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 32 44.750000 2237.5000 50.0000
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 13 12.500000 312.5000 25.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 6 9.000000 450.0000 50.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 9 8.500000 425.0000 50.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 5 9.500000 475.0000 50.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 11 12.000000 600.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 266 1184.500000 56895.5600 48.0334
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 20 59.000000 590.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 46 205.000000 14645.2000 71.4400
OCCT-97530HM-OT SESSION BY OT ASST 3 9.250000 529.1000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 63 269.000000 19217.3600 71.4400
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 197 1275.250000 90500.6800 70.9670
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 1 3.000000 171.6000 57.2000
TRAV-TRAVS-Travel by mile 775 44263.00000 19491.8800 0.4404
Subtotal (Total Children Is Unduplicated) 893 47364.25000 206541.3800 4.3607
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Total 49239.750000 287842.5300 5.8457
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Number of Children (Unduplicated) With at Least One Service 1452
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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
58 68.000000 4208.0800 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 58 68.000000 4208.0800 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 2797 47866.750000 230466.1400 230466.1400
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
16 37.250000 2189.2900 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 2813 47904.000000 232655.4300 230466.1400
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 3 2.250000 160.7400 90.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
39 38.500000 2096.5200 71.4400
Other 0 0.000000 0.0000 0.0000
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Total 42 40.750000 2257.2600 161.4400
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
121 104.750000 7138.2700 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 121 104.750000 7138.2700 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 7 6.500000 298.6000 298.6000
H 0 0.000000 0.0000 0.0000
T 1 4.000000 200.0000 200.0000
872 995.750000 37200.2500 0.0000
Other 50 116.000000 3884.6400 3884.6400
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Total 930 1122.250000 41583.4900 4383.2400