CMS/EIP Fiscal Report Statewide
Services beginning 10/01/2015 ending 12/31/2015 Date of Report:02/13/2016 Page: 1
List order: No List
Payclass Filters:TPIN
Eligibility Filter:Part C (excluding not eligible)
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
CASE-CASE-NON-TCM CASE MANAGEMENT 16 10.250000 379.2500 37.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 10 7.250000 25.0000 3.4483
TCM-T1017TL-TARGETED CASE MANAGEMENT 245 569.750000 21071.5000 36.9838
Subtotal (Total Children Is Unduplicated) 255 587.250000 21475.7500 36.5700
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Screening, Eval, and Assessment,Class #02
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 2 2.000000 20.8400 10.4200
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 2 2.000000 17.5000 8.7500
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 1 1.000000 21.8400 21.8400
EVAL-96111-DEVELOPMENTAL EVALUATION 30 51.000000 10050.0000 197.0588
EXIT-EXIT-EXIT ASSESSMENT 2 3.000000 150.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 16 35.000000 2625.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 11 18.500000 1387.5000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 4 4.500000 337.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 14 20.500000 2190.0000 106.8293
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 10 16.000000 888.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 279 521.806233 38666.2100 74.1007
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 138 224.350734 16726.2900 74.5542
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 64 111.233333 8342.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 193 362.000000 19986.4800 55.2113
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 169 262.000000 23117.5000 88.2347
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 13 13.000000 3784.0000 291.0769
MED-99204-OUTPATIENT VISIT, NEW, 45 MINS 2 2.000000 564.2700 282.1350
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 1 1.000000 280.0000 280.0000
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 15 17.000000 854.4000 50.2588
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 2 2.000000 102.1000 51.0500
PSTH-97001-EVAL BY LICENSED PT, INITIAL 7 11.000000 859.4500 78.1318
SCREEN-T1023-SCREENING 8 8.000000 400.0000 50.0000
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 23 23.000000 1161.3800 50.4948
SPCH-92524-BEHAV & QUAL ANALYSIS OF
VOICE AND RES 3 3.000000 153.1500 51.0500
Subtotal (Total Children Is Unduplicated) 615 1714.890300 132685.9100 77.3728
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 1 2.000000 1347.8800 673.9400
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 3 3.250000 162.5000 50.0000
CONIF-CONIF-CONSULT, FACE TO FACE 5 5.500000 275.0000 50.0000
CONIP-CONIP-CONSULT, PHONE 1 1.000000 25.0000 25.0000
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 1 1.000000 25.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 265 1253.500000 62605.0000 49.9442
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 16 26.000000 260.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 104 436.551634 32567.0400 74.6007
OCCT-97530HM-OT SESSION BY OT ASST 12 44.247282 2530.9400 57.1999
PHY-97110-PT SESSION BY LICENSED PT 173 757.084596 61226.0070 80.8708
PHY-97110HM-PT SESSION BY PT ASST 14 43.349900 2477.8800 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 245 1147.314827 90826.3896 79.1643
SPL-92508-GROUP SPL SESSION PER CHILD 2 8.000000 111.0400 13.8800
TRAV-TRAVS-Travel by mile 1 50.000000 22.2500 0.4450
Subtotal (Total Children Is Unduplicated) 729 3778.798239 254461.9266 67.3394
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Total 6080.938539 408623.5866 67.1975
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Number of Children (Unduplicated) With at Least One Service 1389
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Center 01
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 28 39.500000 2930.3800 0.0000
T 0 0.000000 0.0000 0.0000
0 0.000000 0.0000 0.0000
Other 7 8.500000 549.7500 0.0000
---------------------------------------------------------
Total 35 48.000000 3480.1300 0.0000
Center 02
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 74 73.000000 4545.1300 0.0000
55 66.250000 5965.1300 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 129 139.250000 10510.2600 0.0000
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 206 203.250000 40625.0000 0.0000
T 0 0.000000 0.0000 0.0000
6 5.750000 1200.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 212 209.000000 41825.0000 0.0000
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 28 24.500000 7211.5000 5429.2100
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 1 3.000000 171.4800 0.0000
T 0 0.000000 0.0000 0.0000
50 46.000000 5679.5000 43.1800
Other 36 97.500000 6567.9000 551.1300
---------------------------------------------------------
Total 115 171.000000 19630.3800 6023.5200
Center 05
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 1 2.000000 100.0000 100.0000
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 21.000000 1455.2500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 16 23.000000 1555.2500 100.0000
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
776 655.500000 33050.7700 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 776 655.500000 33050.7700 0.0000
Center 07
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
28 42.250000 2405.1400 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 28 42.250000 2405.1400 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 1 1.000000 71.4400 0.0000
P 112 112.000000 7958.4000 7958.4000
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
253 449.500000 31815.1800 203.2200
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 366 562.500000 39845.0200 8161.6200
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
495 1076.500000 73229.1500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 495 1076.500000 73229.1500 0.0000
Center 51
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
56 130.250000 9125.1200 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 56 130.250000 9125.1200 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 19 28.000000 838.7400 838.7400
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 177 189.250000 12399.4000 7439.0400
505 644.000000 38411.8400 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 701 861.250000 51649.9800 8277.7800
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
637 674.250000 33543.4200 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 637 674.250000 33543.4200 0.0000
Center 54
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
516 540.859480 25233.6512 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 516 540.859480 25233.6512 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
540 387.329059 27289.6154 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 540 387.329059 27289.6154 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 1 3.500000 250.0400 250.0400
H 0 0.000000 0.0000 0.0000
T 1 3.000000 30.0000 30.0000
213 553.500000 35970.6600 35110.6600
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 215 560.000000 36250.7000 35390.7000