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
Agency Filter:EIP DEI DEIP
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
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 13 18.500000 2040.0000 110.2703
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 9 15.000000 832.5000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 244 467.000000 34555.7600 73.9952
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 124 206.500000 15387.5000 74.5157
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 43 77.000000 5775.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 180 342.000000 18876.4800 55.1944
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 155 236.500000 21205.0000 89.6617
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 2 4.000000 204.2000 51.0500
PSTH-97001-EVAL BY LICENSED PT, INITIAL 3 7.000000 655.2500 93.6071
SCREEN-T1023-SCREENING 8 8.000000 400.0000 50.0000
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 1 1.000000 51.0500 51.0500
Subtotal (Total Children Is Unduplicated) 525 1510.500000 119161.0100 78.8885
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 3 3.250000 162.5000 50.0000
CONIF-CONIF-CONSULT, FACE TO FACE 4 4.500000 225.0000 50.0000
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 1 1.000000 25.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 191 864.500000 43155.0000 49.9190
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 11 14.000000 140.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 23 105.500000 9272.4800 87.8908
PHY-97110-PT SESSION BY LICENSED PT 43 181.250000 20853.1800 115.0520
PHY-97110HM-PT SESSION BY PT ASST 2 4.000000 228.6400 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 53 316.750000 33209.8200 104.8455
SPL-92508-GROUP SPL SESSION PER CHILD 1 4.000000 55.5200 13.8800
Subtotal (Total Children Is Unduplicated) 305 1498.750000 107327.1400 71.6111
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Total 3596.500000 247963.9000 68.9459
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Number of Children (Unduplicated) With at Least One Service 947
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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 1 1.000000 75.0000 0.0000
---------------------------------------------------------
Total 29 40.500000 3005.3800 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 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
50 46.000000 5679.5000 43.1800
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 78 70.500000 12891.0000 5472.3900
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 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 21.000000 1455.2500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 15 21.000000 1455.2500 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
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
21 28.250000 1625.5000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 21 28.250000 1625.5000 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
146 166.000000 11976.5800 203.2200
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 259 279.000000 20006.4200 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
286 623.250000 43770.7500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 286 623.250000 43770.7500 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
9 34.000000 2428.9600 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 9 34.000000 2428.9600 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 158 167.250000 10848.7500 7162.5000
358 418.500000 24809.6300 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 535 613.750000 36497.1200 8001.2400
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
549 581.250000 28802.2500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 549 581.250000 28802.2500 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
428 398.000000 19495.5000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 428 398.000000 19495.5000 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
15 30.000000 2250.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 15 30.000000 2250.0000 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
12 12.500000 860.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 12 12.500000 860.0000 0.0000