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: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 15 10.000000 370.0000 37.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 3 1.500000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 259 478.750000 17695.2500 36.9614
Subtotal (Total Children Is Unduplicated) 266 490.250000 18065.2500 36.8491
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Screening, Eval, and Assessment,Class #02
EVAL-96111-DEVELOPMENTAL EVALUATION 72 127.000000 23420.0000 184.4094
EXIT-EXIT-EXIT ASSESSMENT 1 1.500000 75.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 19 37.000000 2678.1300 72.3819
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 9 13.500000 739.7100 54.7933
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 15 31.000000 1673.8800 53.9961
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 406 715.415901 52034.9000 72.7338
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 173 271.394100 19363.6200 71.3487
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 75 130.234078 9680.9200 74.3348
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 370 652.000000 35841.5800 54.9717
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 218 345.481067 25798.5800 74.6744
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 6 6.000000 1824.0000 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
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 1 1.000000 51.0500 51.0500
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 15 18.000000 867.8500 48.2139
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 4 3.447200 175.9800 51.0501
PSTH-97001-EVAL BY LICENSED PT, INITIAL 12 12.000000 716.5700 59.7142
SCREEN-T1023-SCREENING 14 14.000000 700.0000 50.0000
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 14 13.881489 708.6500 51.0500
SPCH-92524-BEHAV & QUAL ANALYSIS OF
VOICE AND RES 2 1.090000 56.0500 51.4220
Subtotal (Total Children Is Unduplicated) 865 2409.943835 177689.0100 73.7316
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 3 3.000000 640.4100 213.4700
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 5 5.750000 287.5000 50.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 1 0.500000 25.0000 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 222 1125.300000 56752.5000 50.4332
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 4 5.000000 50.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 116 513.329466 37155.2000 72.3808
OCCT-97530HM-OT SESSION BY OT ASST 22 62.125527 3553.5800 57.2000
PHY-97110-PT SESSION BY LICENSED PT 153 675.440419 58921.1800 87.2337
PHY-97110HM-PT SESSION BY PT ASST 21 72.339123 3946.2600 54.5522
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 212 930.819035 77613.9500 83.3824
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 1 1.500000 85.8000 57.2000
SPL-92508-GROUP SPL SESSION PER CHILD 4 12.250000 170.0300 13.8800
TRAV-TRAVS-Travel by mile 9 166.000000 73.9000 0.4452
Subtotal (Total Children Is Unduplicated) 651 3576.353570 239350.3100 66.9258
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Total 6476.547405 435104.5700 67.1816
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Number of Children (Unduplicated) With at Least One Service 1537
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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 6 6.000000 410.7800 285.7600
12 12.000000 835.8400 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 18 18.000000 1246.6200 285.7600
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 333 331.750000 64284.3200 0.0000
T 0 0.000000 0.0000 0.0000
15 14.250000 1557.5900 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 348 346.000000 65841.9100 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 7 7.000000 521.4400 1390.1100
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
73 72.000000 6868.0500 0.0000
Other 46 108.000000 7353.0400 645.1400
---------------------------------------------------------
Total 126 187.000000 14742.5300 2035.2500
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 2 2.000000 122.4900 122.4900
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
48 70.000000 5186.8900 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 50 72.000000 5309.3800 122.4900
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
754 695.000000 36236.5400 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 754 695.000000 36236.5400 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
9 11.000000 550.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 9 11.000000 550.0000 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
174 330.500000 23650.1200 300.5400
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 338 495.000000 35414.4600 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 2 1.500000 65.4500 25.4500
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 0 0.000000 0.0000 0.0000
652 1392.000000 94018.7700 511.8600
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 654 1393.500000 94084.2200 537.3100
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
61 136.000000 9440.5600 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 61 136.000000 9440.5600 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 66 114.500000 3813.3600 3545.3800
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 5 123.500000 180.5600 180.5600
585 833.250000 50817.7400 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 656 1071.250000 54811.6600 3725.9400
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
651 742.550000 38736.6800 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 651 742.550000 38736.6800 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
503 545.237778 27798.4900 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 503 545.237778 27798.4900 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 23 44.000000 3300.0000 0.0000
T 0 0.000000 0.0000 0.0000
602 417.509627 28454.4500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 625 461.509627 31754.4500 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
134 302.500000 19137.0700 17223.8200
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 134 302.500000 19137.0700 17223.8200