CMS/EIP Fiscal Report Statewide
Services beginning 07/01/2016 ending 09/30/2016 Date of Report:10/31/2016 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
TCM-T1017TL-TARGETED CASE MANAGEMENT 4 9.750000 360.7500 37.0000
Subtotal (Total Children Is Unduplicated) 4 9.750000 360.7500 37.0000
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Screening, Eval, and Assessment,Class #02
EVAL-96111-DEVELOPMENTAL EVALUATION 17 32.000000 7806.0000 243.9375
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 2 3.000000 225.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 2 3.000000 225.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 2 3.500000 262.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 3 3.500000 262.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 4 7.500000 416.2500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 82 134.990400 9933.6200 73.5876
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 50 79.000000 5819.7100 73.6672
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 26 41.000000 3075.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 89 145.500000 8038.6000 55.2481
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 56 71.000000 6600.4200 92.9637
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 3 3.000000 738.5500 246.1833
Subtotal (Total Children Is Unduplicated) 205 526.990400 43403.1500 82.3604
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Total 536.740400 43763.9000 81.5364
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Number of Children (Unduplicated) With at Least One Service 205
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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 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
4 8.000000 522.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 4 8.000000 522.0000 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 28 28.000000 7456.0000 0.0000
T 0 0.000000 0.0000 0.0000
2 2.000000 250.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 30 30.000000 7706.0000 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 8 7.500000 1893.4700 1893.4700
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
18 19.000000 1883.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 26 26.500000 3776.4700 1893.4700
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
28 34.500000 2343.7500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 28 34.500000 2343.7500 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 1 1.000000 55.5000 55.5000
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
80 108.500000 7728.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 81 109.500000 7783.5000 55.5000
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
99 178.000000 12082.5000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 99 178.000000 12082.5000 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 4 8.000000 328.4000 328.4000
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 1 2.000000 150.0000 130.0000
34 65.250000 3838.2500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 39 75.250000 4316.6500 458.4000
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
19 28.500000 1854.7500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 19 28.500000 1854.7500 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
17 23.500000 1704.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 17 23.500000 1704.0000 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 1 0.990400 74.2800 0.0000
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 2 4.000000 300.0000 0.0000
T 0 0.000000 0.0000 0.0000
9 18.000000 1300.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 12 22.990400 1674.2800 0.0000