CMS/EIP Fiscal Report Statewide
Services beginning 10/01/2019 ending 12/31/2019 Date of Report:02/01/2020 Page: 1
List order: No List
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
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 67 42.000000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 73 124.250000 4569.5000 36.7767
Subtotal (Total Children Is Unduplicated) 73 166.250000 4569.5000 27.4857
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Screening, Eval, and Assessment,Class #02
EXIT-EXIT-EXIT ASSESSMENT 9 18.250000 912.5000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 2 3.000000 225.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 2.000000 150.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 1 1.500000 112.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 3 5.000000 277.5000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 33 54.000000 4050.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 36 66.500000 4987.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 67 117.500000 6521.2500 55.5000
NUTR-97802-NUTRITIONAL EVAL, INITIAL 1 3.000000 150.0000 50.0000
NUTR-97803-NUTRITIONAL EVAL, FOLLOW-UP 5 22.000000 1100.0000 50.0000
OCTH-97167-OT EVAL HIGH COMPLEXITY 2 2.000000 102.1000 51.0500
Subtotal (Total Children Is Unduplicated) 89 294.750000 18588.3500 63.0648
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 11 14.750000 737.5000 50.0000
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 3 3.000000 75.0000 25.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 7 6.000000 300.0000 50.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 2 2.000000 100.0000 50.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 1 1.000000 50.0000 50.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 11 11.000000 550.0000 50.0000
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 1 3.000000 75.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 274 1218.000000 60751.0100 49.8777
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 48 104.000000 1040.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 37 146.000000 10430.2400 71.4400
OCCT-97530HM-OT SESSION BY OT ASST 5 21.750000 1244.1000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 66 231.500000 16538.3600 71.4400
PHY-97110HM-PT SESSION BY PT ASST 2 3.500000 200.0600 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 175 1119.250000 79959.2200 71.4400
TRAV-TRAVS-Travel by mile 946 49817.00000 21681.4100 0.4352
Subtotal (Total Children Is Unduplicated) 1069 52701.75000 193731.9000 3.6760
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Total 53162.750000 216889.7500 4.0797
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Number of Children (Unduplicated) With at Least One Service 1129
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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
118 123.250000 6627.0400 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 118 123.250000 6627.0400 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 2395 52353.500000 178349.9200 178349.9200
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 274 402.500000 20147.7500 0.0000
T 0 0.000000 0.0000 0.0000
0 0.000000 0.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 2669 52756.000000 198497.6700 178349.9200
Center 10
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 0.500000 35.7200 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 1 0.500000 35.7200 0.0000
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 0 0.000000 0.0000 0.0000
15 14.000000 705.7600 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 15 14.000000 705.7600 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
122 120.500000 7353.8300 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 122 120.500000 7353.8300 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 100 148.500000 3669.7300 3669.7300
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Total 100 148.500000 3669.7300 3669.7300