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
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 144 86.500000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 163 268.000000 9869.7500 36.8274
Subtotal (Total Children Is Unduplicated) 163 354.500000 9869.7500 27.8413
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Screening, Eval, and Assessment,Class #02
EXIT-EXIT-EXIT ASSESSMENT 9 17.500000 875.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 4 6.500000 487.5000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 3 5.500000 412.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 6 10.500000 582.7500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 80 120.000000 9000.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 69 122.000000 9150.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 6 10.500000 787.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 150 243.500000 13514.2500 55.5000
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) 184 604.500000 38329.3500 63.4067
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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 9 9.000000 450.0000 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 262 1334.000000 66700.0000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 20 36.000000 360.0000 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 180 963.000000 68796.7200 71.4400
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 32 116.000000 6466.6000 55.7466
TRAV-TRAVS-Travel by mile 831 51604.00000 22598.3300 0.4379
Subtotal (Total Children Is Unduplicated) 1005 55584.00000 231926.2700 4.1725
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Total 56543.000000 280125.3700 4.9542
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Number of Children (Unduplicated) With at Least One Service 1169
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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 2519 54515.750000 198696.4000 198696.4000
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 413 569.750000 28409.7500 0.0000
T 0 0.000000 0.0000 0.0000
6 6.250000 300.1300 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 2938 55091.750000 227406.2800 198696.4000
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
28 54.250000 1213.8700 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 29 56.250000 1242.4300 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
66 63.500000 3850.4800 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 66 63.500000 3850.4800 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
---------------------------------------------------------
Total 176 499.500000 22586.5000 22755.1000