CMS/EIP Fiscal Report Statewide
Services beginning 01/01/2016 ending 03/31/2016 Date of Report:05/12/2016 Page: 1
List order: No List
Payclass Filters:TPIN
Eligibility Filter:Not Part C
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
CASE-CASE-NON-TCM CASE MANAGEMENT 3 5.500000 203.5000 37.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 1 0.750000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 25 38.250000 1406.0000 36.7582
Subtotal (Total Children Is Unduplicated) 28 44.500000 1609.5000 36.1685
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Screening, Eval, and Assessment,Class #02
EVAL-96111-DEVELOPMENTAL EVALUATION 35 63.000000 11020.0000 174.9206
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 2 4.000000 300.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 2 2.500000 102.2100 40.8840
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 2 3.500000 185.3500 52.9571
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 104 168.461967 12033.9800 71.4344
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 44 61.040400 4459.9500 73.0655
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 19 36.164478 2625.7100 72.6047
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 87 149.500000 8192.7900 54.8013
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 46 59.981067 4423.5800 73.7496
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 1 1.000000 304.0000 304.0000
Subtotal (Total Children Is Unduplicated) 212 549.147912 43647.5700 79.4824
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Total 593.647912 45257.0700 76.2355
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Number of Children (Unduplicated) With at Least One Service 217
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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 55 61.000000 10820.0000 0.0000
T 0 0.000000 0.0000 0.0000
2 4.000000 400.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 57 65.000000 11220.0000 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 3 3.000000 225.0000 638.2400
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 12.000000 1129.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 15 15.000000 1354.0000 638.2400
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
12 19.000000 1425.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 12 19.000000 1425.0000 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
84 85.750000 4804.5000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 84 85.750000 4804.5000 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 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
22 31.000000 2325.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 22 31.000000 2325.0000 0.0000
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
104 194.500000 13212.7500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 104 194.500000 13212.7500 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 15 28.500000 1026.6500 896.6500
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
29 55.500000 3448.4200 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 44 84.000000 4475.0700 896.6500
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
28 35.500000 1965.7500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 28 35.500000 1965.7500 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
20 25.247778 1605.5000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 20 25.247778 1605.5000 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 10 18.000000 1350.0000 0.0000
T 0 0.000000 0.0000 0.0000
15 15.150134 1136.2500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 25 33.150134 2486.2500 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
6 5.500000 383.2500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 6 5.500000 383.2500 0.0000