CMS/EIP Fiscal Report Statewide
Services beginning 10/01/2016 ending 12/31/2016 Date of Report:02/04/2017 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
CASE-CASE-NON-TCM CASE MANAGEMENT 1 0.500000 18.5000 37.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 1 1.000000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 6 18.000000 666.0000 37.0000
Subtotal (Total Children Is Unduplicated) 8 19.500000 684.5000 35.1026
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Screening, Eval, and Assessment,Class #02
EVAL-96111-DEVELOPMENTAL EVALUATION 2 4.000000 1628.0000 407.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 3 3.666667 275.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 1.000000 75.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 1 1.500000 112.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 1 1.500000 83.2500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 95 156.814000 11530.7200 73.5312
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 42 67.500000 4917.1700 72.8470
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 28 44.000000 3085.2600 70.1195
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 96 158.500000 8796.7500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 49 71.000000 5312.5000 74.8239
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 1 1.000000 304.0000 304.0000
Subtotal (Total Children Is Unduplicated) 187 510.480667 36120.1500 70.7571
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EI Services,Class #03
TRAV-TRAVS-Travel by mile 2 38.000000 16.9100 0.4450
Subtotal (Total Children Is Unduplicated) 2 38.000000 16.9100 0.4450
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Total 567.980667 36821.5600 64.8289
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Number of Children (Unduplicated) With at Least One Service 190
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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 1 1.500000 83.2500 83.2500
D 11 15.000000 1017.7500 0.0000
S 7 12.000000 831.7500 0.0000
H 8 11.000000 825.0000 0.0000
T 0 0.000000 0.0000 0.0000
1 1.500000 83.2500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 28 41.000000 2841.0000 83.2500
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 2 2.000000 1528.0000 0.0000
T 0 0.000000 0.0000 0.0000
0 0.000000 0.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 2 2.000000 1528.0000 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 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
8 7.500000 791.5000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 8 7.500000 791.5000 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
44 60.500000 4040.2500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 44 60.500000 4040.2500 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
1 0.500000 18.5000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 1 0.500000 18.5000 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 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
44 61.500000 4387.0000 0.0000
Other 2 3.500000 262.5000 0.0000
---------------------------------------------------------
Total 46 65.000000 4649.5000 0.0000
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
76 134.000000 9084.7500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 76 134.000000 9084.7500 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 8 15.500000 701.2600 568.4700
D 6 11.000000 649.5000 0.0000
S 0 0.000000 0.0000 0.0000
H 1 2.000000 150.0000 0.0000
T 0 0.000000 0.0000 0.0000
38 72.250000 4352.0900 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 53 100.750000 5852.8500 568.4700
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
36 51.750000 3339.5000 0.0000
Other 1 1.500000 112.5000 0.0000
---------------------------------------------------------
Total 37 53.250000 3452.0000 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
28 73.500000 2364.6600 325.1600
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 28 73.500000 2364.6600 325.1600
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 7 14.000000 1050.0000 0.0000
T 0 0.000000 0.0000 0.0000
10 15.980667 1148.5500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 17 29.980667 2198.5500 0.0000