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
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 12 4.500000 166.5000 37.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 2 0.750000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 234 440.500000 16289.2500 36.9790
Subtotal (Total Children Is Unduplicated) 238 445.750000 16455.7500 36.9170
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Screening, Eval, and Assessment,Class #02
EVAL-96111-DEVELOPMENTAL EVALUATION 37 64.000000 12400.0000 193.7500
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 17 33.000000 2378.1300 72.0645
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 4 8.500000 637.5000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 6 9.000000 487.5000 54.1667
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 5 4.500000 337.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 13 27.500000 1488.5300 54.1284
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 289 528.083334 38585.6400 73.0673
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 119 200.000000 14127.1500 70.6358
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 49 83.000000 6225.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 277 491.500000 27038.2900 55.0118
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 166 276.000000 20700.0000 75.0000
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 5 5.000000 1520.0000 304.0000
MED-99204-OUTPATIENT VISIT, NEW, 45 MINS 2 2.000000 114.5400 57.2700
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 1 1.000000 193.0000 193.0000
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 1 2.000000 51.0500 25.5250
PSTH-97001-EVAL BY LICENSED PT, INITIAL 4 4.000000 353.1500 88.2875
SCREEN-T1023-SCREENING 14 14.000000 700.0000 50.0000
Subtotal (Total Children Is Unduplicated) 602 1753.083334 127336.9800 72.6360
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 5 5.750000 287.5000 50.0000
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 2 3.000000 75.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 158 806.500000 40812.5000 50.6045
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 3 4.000000 40.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 22 108.000000 8578.2400 79.4281
PHY-97110-PT SESSION BY LICENSED PT 43 195.000000 25934.1200 132.9955
PHY-97110HM-PT SESSION BY PT ASST 4 19.000000 897.4000 47.2316
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 62 318.750000 36180.8400 113.5085
TRAV-TRAVS-Travel by mile 3 120.000000 53.4000 0.4450
Subtotal (Total Children Is Unduplicated) 278 1580.000000 112859.0000 71.4297
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Total 3778.833334 256651.7300 67.9182
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Number of Children (Unduplicated) With at Least One Service 961
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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 278 270.750000 53464.3200 0.0000
T 0 0.000000 0.0000 0.0000
11 8.250000 1138.7500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 289 279.000000 54603.0700 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 680.4300
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
60 59.000000 5688.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 63 62.000000 5913.0000 680.4300
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
36 51.000000 3761.8900 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 36 51.000000 3761.8900 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
670 609.250000 31432.0400 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 670 609.250000 31432.0400 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 164 164.500000 11764.3400 270829.0300
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
108 130.500000 9364.0300 300.5400
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 272 295.000000 21128.3700 271129.5700
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
353 745.500000 51573.7500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 353 745.500000 51573.7500 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
4 11.000000 785.8400 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 4 11.000000 785.8400 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 50 84.000000 2727.1400 2589.1600
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 4 122.000000 73.4000 73.4000
424 482.250000 29592.7300 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 478 688.250000 32393.2700 2662.5600
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
551 611.000000 31803.2500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 551 611.000000 31803.2500 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
356 357.750000 18271.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 356 357.750000 18271.0000 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 13 26.000000 1950.0000 0.0000
T 0 0.000000 0.0000 0.0000
12 20.083334 1506.2500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 25 46.083334 3456.2500 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
24 23.000000 1530.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 24 23.000000 1530.0000 0.0000