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
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 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
EVAL-96111-DEVELOPMENTAL EVALUATION 25 43.000000 14524.0000 337.7674
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 1 2.000000 150.0000 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 12 22.000000 1221.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 237 458.782400 33911.2600 73.9158
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 138 232.000000 17084.3700 73.6395
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 44 72.500000 5337.5000 73.6207
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 280 536.000000 29677.0000 55.3675
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 169 279.000000 22850.5600 81.9016
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
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 2 2.000000 102.1000 51.0500
SCREEN-T1023-SCREENING 9 9.000000 404.8900 44.9878
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 6 6.000000 455.2500 75.8750
Subtotal (Total Children Is Unduplicated) 590 1737.782400 134609.0800 77.4603
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EI Services,Class #03
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 200 1046.250000 52375.0000 50.0597
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 10 14.000000 140.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 17 77.250000 5518.7400 71.4400
PHY-97110-PT SESSION BY LICENSED PT 22 65.750000 8766.1600 133.3256
PHY-97110HM-PT SESSION BY PT ASST 3 35.000000 2000.6000 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 83 376.000000 36730.8800 97.6885
Subtotal (Total Children Is Unduplicated) 316 1631.500000 106505.4400 65.2807
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Total 3532.032400 246923.5200 69.9098
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Number of Children (Unduplicated) With at Least One Service 890
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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 1 1.000000 75.0000 0.0000
H 49 63.000000 4628.8000 0.0000
T 0 0.000000 0.0000 0.0000
5 5.000000 250.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 57 72.000000 5120.3000 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 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
59 60.000000 6568.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 83 85.000000 11529.2100 4961.2100
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
11 15.000000 1110.7600 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 11 15.000000 1110.7600 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
209 337.000000 22301.7500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 209 337.000000 22301.7500 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 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
159 195.500000 13362.8900 140.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 251 287.000000 19810.6700 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
302 639.000000 44454.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 302 639.000000 44454.0000 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
6 16.000000 1143.0400 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 6 16.000000 1143.0400 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 2 4.750000 93.5800 103.3100
622 687.250000 39281.2300 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 775 855.750000 48355.1500 5544.8100
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
595 677.000000 35518.3100 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 595 677.000000 35518.3100 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
378 390.500000 20411.5000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 381 393.500000 20561.5000 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
13 13.750000 976.1500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 33 52.532400 3884.8300 0.0000