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: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 5 1.500000 55.5000 37.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 5 5.750000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 61 165.250000 6114.2500 37.0000
Subtotal (Total Children Is Unduplicated) 67 172.500000 6169.7500 35.7667
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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 43 75.750000 22367.5000 295.2805
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 15 25.000000 1875.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 4 7.000000 525.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 6 11.500000 862.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 27 36.000000 3288.0500 91.3347
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 17 31.500000 1748.2500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 375 689.218733 50898.3200 73.8493
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 204 337.153467 24865.5900 73.7515
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 114 191.000000 14153.5100 74.1021
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 385 705.500000 39047.6000 55.3474
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 235 366.490667 30687.7800 83.7341
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 17 17.000000 4168.9000 245.2294
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) 897 2563.092299 198336.0100 77.3815
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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 6782.264481 457391.1000 67.4393
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Number of Children (Unduplicated) With at Least One Service 1521
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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
22 30.500000 1840.7500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 160 184.500000 11892.3100 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 131 129.250000 40390.0000 0.0000
T 0 0.000000 0.0000 0.0000
3 3.000000 450.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 134 132.250000 40840.0000 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 32 32.500000 6854.6800 6854.6800
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
77 79.000000 8451.0000 0.0000
Other 48 113.500000 7751.9500 1229.8900
---------------------------------------------------------
Total 159 232.000000 23443.4300 8084.5700
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
237 371.500000 24645.5000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 237 371.500000 24645.5000 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 89 88.500000 6217.5200 6469.5500
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
430 787.500000 55862.1600 140.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 523 880.000000 62365.4400 6609.5500
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
517 1046.250000 72165.6100 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 517 1046.250000 72165.6100 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 152 167.750000 9054.8600 5769.9000
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 4 8.750000 386.4600 376.1900
832 1110.750000 63970.5500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 991 1291.250000 73665.7500 6146.0900
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
763 859.490667 45230.3600 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 763 859.490667 45230.3600 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
477 682.500000 26882.5100 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 480 685.500000 27032.5100 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 3 3.772800 282.9600 0.0000
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 20 40.000000 3000.0000 0.0000
T 0 0.000000 0.0000 0.0000
801 667.221014 46626.7400 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 824 710.993814 49909.7000 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