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: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 5 1.500000 55.5000 37.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 5 5.750000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 57 155.500000 5753.5000 37.0000
Subtotal (Total Children Is Unduplicated) 63 162.750000 5809.0000 35.6928
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Screening, Eval, and Assessment,Class #02
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 1 1.000000 10.4200 10.4200
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 1 1.000000 8.7500 8.7500
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 1 1.000000 21.8400 21.8400
EVAL-96111-DEVELOPMENTAL EVALUATION 26 43.750000 14561.5000 332.8343
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 13 22.000000 1650.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 2 4.000000 300.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 4 8.000000 600.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 24 32.500000 3025.5500 93.0938
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 13 24.000000 1332.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 293 554.228333 40964.7000 73.9130
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 154 258.153467 19045.8800 73.7774
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 88 150.000000 11078.5100 73.8567
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 296 560.000000 31009.0000 55.3732
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 179 295.490667 24087.3600 81.5165
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 14 14.000000 3430.3500 245.0250
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 3 3.000000 485.2500 161.7500
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 2 2.000000 102.1000 51.0500
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 20 20.000000 994.9500 49.7475
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 2 2.000000 102.1000 51.0500
PSTH-97001-EVAL BY LICENSED PT, INITIAL 5 4.979432 241.4600 48.4915
SCREEN-T1023-SCREENING 9 9.000000 404.8900 44.9878
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 26 26.000000 1476.2500 56.7788
Subtotal (Total Children Is Unduplicated) 692 2036.101899 154932.8600 76.0929
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 1 0.482000 252.3800 523.6100
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 2 2.000000 100.0000 50.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 4 4.250000 212.5000 50.0000
COUN-H2019HR-INDIVIDUAL/FAMILY THERAPY 2 8.000000 586.5600 73.3200
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 1 3.000000 75.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 267 1351.250000 67625.0000 50.0463
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 15 25.000000 250.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 115 484.850299 34091.5900 70.3136
OCCT-97530HM-OT SESSION BY OT ASST 14 59.035116 3376.7800 57.1995
PHY-97110-PT SESSION BY LICENSED PT 145 632.249397 48764.8400 77.1291
PHY-97110HM-PT SESSION BY PT ASST 16 80.173196 4582.7000 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 269 1206.382174 92869.9900 76.9822
SPL-92508-GROUP SPL SESSION PER CHILD 1 1.000000 13.8800 13.8800
TRAV-TRAVS-Travel by mile 4 189.000000 84.1200 0.4451
Subtotal (Total Children Is Unduplicated) 716 4046.672182 252885.3400 62.4922
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Total 6245.524081 413627.2000 66.2278
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Number of Children (Unduplicated) With at Least One Service 1316
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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 2 3.000000 166.5000 0.0000
S 83 83.000000 4910.5100 0.0000
H 49 63.000000 4628.8000 0.0000
T 4 5.000000 345.7500 225.7500
18 22.500000 1318.7500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 156 176.500000 11370.3100 225.7500
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 0 0.000000 0.0000 0.0000
14 7.000000 500.0800 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 14 7.000000 500.0800 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 103 101.250000 32934.0000 0.0000
T 0 0.000000 0.0000 0.0000
1 1.000000 200.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 104 102.250000 33134.0000 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 24 25.000000 4961.2100 4961.2100
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 2 7.000000 385.8000 0.0000
T 0 0.000000 0.0000 0.0000
59 60.000000 6568.0000 0.0000
Other 48 113.500000 7751.9500 1229.8900
---------------------------------------------------------
Total 133 205.500000 19666.9600 6191.1000
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 15.500000 1146.4800 35.7200
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 12 15.500000 1146.4800 35.7200
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
209 337.000000 22301.7500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 209 337.000000 22301.7500 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 1 4.000000 40.0000 40.0000
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
3 4.000000 221.4400 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 4 8.000000 261.4400 40.0000
Center 09
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 2 2.000000 142.8800 0.0000
P 88 87.500000 6162.0200 6414.0500
D 2 2.000000 142.8800 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
350 679.000000 48134.1600 140.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 442 770.500000 54581.9400 6554.0500
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
418 868.250000 60083.1100 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 418 868.250000 60083.1100 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
50 124.250000 8822.9900 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 50 124.250000 8822.9900 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 148 159.750000 8726.4600 5441.5000
D 3 4.000000 253.8800 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 3 6.750000 236.4600 246.1900
798 1045.500000 60132.3000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 952 1216.000000 69349.1000 5687.6900
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
744 830.990667 43375.6100 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 744 830.990667 43375.6100 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 3 3.000000 150.0000 199.8000
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
460 659.000000 25178.5100 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 463 662.000000 25328.5100 199.8000
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 2 2.782400 208.6800 0.0000
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 18 36.000000 2700.0000 0.0000
T 0 0.000000 0.0000 0.0000
792 649.221014 45326.7400 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 812 688.003414 48235.4200 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 3 3.780000 270.0400 270.0400
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
106 230.000000 15199.4600 15199.4600
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 109 233.780000 15469.5000 15469.5000