CMS/EIP Fiscal Report Statewide
Services beginning 07/01/2019 ending 09/30/2019 Date of Report:11/04/2019 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
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 1 1.500000 55.5000 37.0000
Subtotal (Total Children Is Unduplicated) 1 1.500000 55.5000 37.0000
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Screening, Eval, and Assessment,Class #02
EXIT-EXIT-EXIT ASSESSMENT 9 17.500000 875.0000 50.0000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 1 1.500000 112.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 3 6.000000 450.0000 75.0000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 2 3.500000 262.5000 75.0000
NUTR-97802-NUTRITIONAL EVAL, INITIAL 1 9.000000 450.0000 50.0000
NUTR-97803-NUTRITIONAL EVAL, FOLLOW-UP 5 49.000000 2450.0000 50.0000
OCTH-97165-OT EVAL LOW COMPLEXITY 1 1.000000 51.0500 51.0500
OCTH-97167-OT EVAL HIGH COMPLEXITY 2 2.000000 102.1000 51.0500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 4 4.000000 204.2000 51.0500
Subtotal (Total Children Is Unduplicated) 27 93.500000 4957.3500 53.0198
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EI Services,Class #03
AUD-92593TS-AUDIOLOGY SERVICES (Biaural) 1 1.000000 50.0000 50.0000
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 9 12.500000 625.0000 50.0000
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 4 4.000000 100.0000 25.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 4 4.000000 200.0000 50.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 8 8.000000 400.0000 50.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 1 1.000000 50.0000 50.0000
CONPP-CONPP-CONSULT, PT, PHONE 1 0.500000 12.5000 25.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 8 8.000000 400.0000 50.0000
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 39 844.500000 21112.5000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 260 1332.000000 66600.0000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 19 35.000000 350.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 53 253.000000 18074.3200 71.4400
OCCT-97530HM-OT SESSION BY OT ASST 29 89.500000 5119.4000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 50 248.500000 17638.5200 70.9800
PHY-97110HM-PT SESSION BY PT ASST 14 55.500000 3172.3800 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 177 956.250000 68314.5000 71.4400
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 32 116.000000 6466.6000 55.7466
TRAV-TRAVS-Travel by mile 830 51603.00000 22597.8900 0.4379
Subtotal (Total Children Is Unduplicated) 997 55572.25000 231283.6100 4.1619
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Total 55667.250000 236296.4600 4.2448
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Number of Children (Unduplicated) With at Least One Service 1012
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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
54 692.000000 17300.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 54 692.000000 17300.0000 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
142 140.000000 7739.6800 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 142 140.000000 7739.6800 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 2317 54230.750000 184205.1500 184205.1500
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 2 3.000000 168.0000 0.0000
T 0 0.000000 0.0000 0.0000
1 2.000000 142.8800 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 2320 54235.750000 184516.0300 184205.1500
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 2.000000 28.5600 28.5600
16 42.500000 571.2100 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 17 44.500000 599.7700 28.5600
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
56 55.500000 3554.4800 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 56 55.500000 3554.4800 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 1 1.000000 51.0500 51.0500
144 449.500000 21336.8500 21505.4500
Other 31 49.000000 1198.6000 1198.6000
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Total 176 499.500000 22586.5000 22755.1000