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:Program Patients
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
CASE-CASE-NON-TCM CASE MANAGEMENT 18 11.500000 425.5000 37.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 11 8.500000 25.0000 2.9412
TCM-T1017TL-TARGETED CASE MANAGEMENT 272 649.500000 24059.2500 37.0427
Subtotal (Total Children Is Unduplicated) 282 669.500000 24509.7500 36.6090
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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 56 97.000000 19250.0000 198.4536
EXIT-EXIT-EXIT ASSESSMENT 2 3.000000 150.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 17 36.500000 2737.5000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 13 20.000000 1500.0000 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 16 23.500000 2415.0000 102.7660
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 11 18.500000 1026.7500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 387 702.630699 52129.4500 74.1918
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 162 259.491134 19361.8200 74.6146
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 89 150.233333 11267.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 271 502.000000 27700.1900 55.1797
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 209 321.500000 28642.5000 89.0902
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 17 17.000000 4952.0000 291.2941
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 24 24.000000 1212.4300 50.5179
SPCH-92524-BEHAV & QUAL ANALYSIS OF
VOICE AND RES 3 3.000000 153.1500 51.0500
Subtotal (Total Children Is Unduplicated) 815 2228.855166 175956.1900 78.9447
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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 246 1149.314827 90969.2696 79.1509
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) 730 3780.798239 254604.8066 67.3415
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Total 6679.153405 455070.7466 68.1330
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Number of Children (Unduplicated) With at Least One Service 1599
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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 34 48.500000 3605.3800 0.0000
T 0 0.000000 0.0000 0.0000
0 0.000000 0.0000 0.0000
Other 8 9.500000 605.2500 0.0000
---------------------------------------------------------
Total 42 58.000000 4210.6300 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 80 85.000000 5406.1300 0.0000
55 66.250000 5965.1300 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 135 151.250000 11371.2600 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 251 248.250000 49625.0000 0.0000
T 0 0.000000 0.0000 0.0000
7 6.750000 1400.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 258 255.000000 51025.0000 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 36 32.000000 9270.5000 7110.7500
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
60 55.500000 6826.0000 43.1800
Other 36 97.500000 6567.9000 551.1300
---------------------------------------------------------
Total 133 188.000000 22835.8800 7705.0600
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
19 26.500000 1867.7500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 20 28.500000 1967.7500 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
859 732.500000 37213.0200 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 859 732.500000 37213.0200 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
30 46.250000 2705.1400 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 30 46.250000 2705.1400 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
286 493.500000 35115.1800 203.2200
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 399 606.500000 43145.0200 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
585 1252.000000 85046.1500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 585 1252.000000 85046.1500 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
57 132.250000 9268.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 57 132.250000 9268.0000 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 20 30.000000 893.4500 893.4500
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 193 220.250000 14461.1500 9205.3100
531 687.000000 40978.8000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 744 937.250000 56333.4000 10098.7600
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
678 737.750000 36997.6700 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 678 737.750000 36997.6700 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
551 584.609480 27788.1512 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 551 584.609480 27788.1512 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
554 408.293925 28861.9254 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 554 408.293925 28861.9254 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
214 554.500000 36021.7100 35161.7100
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 216 561.000000 36301.7500 35441.7500