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: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 10 3.500000 129.5000 37.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 12 9.750000 1300.0000 133.3333
TCM-T1017TL-TARGETED CASE MANAGEMENT 61 116.750000 4319.7500 37.0000
Subtotal (Total Children Is Unduplicated) 74 130.000000 5749.2500 44.2250
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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) 2 2.000000 17.5000 8.7500
AUDE-92568-ACOUSTIC REFLEX TESTING (MEMR) 1 1.000000 8.0600 8.0600
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 1 1.000000 21.8400 21.8400
EVAL-96111-DEVELOPMENTAL EVALUATION 2 2.000000 1353.0000 676.5000
EXIT-EXIT-EXIT ASSESSMENT 3 4.000000 200.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 25 47.000000 3525.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 16 28.000000 2100.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 3 4.500000 272.5400 60.5644
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 27 34.500000 2903.2500 84.1522
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 13 25.000000 1337.5000 53.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 298 516.951503 38415.7404 74.3121
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 151 249.458300 18471.4900 74.0464
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 72 114.908400 8618.1300 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 254 441.500000 24131.7200 54.6585
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 166 251.000000 19677.4200 78.3961
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 13 13.000000 3952.0000 304.0000
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 2 2.000000 386.0000 193.0000
NUTR-97803-NUTRITIONAL EVAL, FOLLOW-UP 12 49.000000 2450.0000 50.0000
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 1 1.000000 51.0500 51.0500
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 13 13.000000 640.2000 49.2462
PSTH-97001-EVAL BY LICENSED PT, INITIAL 12 12.489800 4830.2500 386.7356
SCREEN-T1023-SCREENING 9 9.000000 450.0000 50.0000
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 26 26.000000 1327.3000 51.0500
SPCH-92524-BEHAV & QUAL ANALYSIS OF
VOICE AND RES 1 1.000000 51.0500 51.0500
Subtotal (Total Children Is Unduplicated) 657 1850.308003 135201.4604 73.0697
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 2 2.000000 130.2000 65.1000
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 3 3.000000 150.0000 50.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 9 7.750000 387.5000 50.0000
CONIP-CONIP-CONSULT, ITDS PHONE 1 1.000000 25.0000 25.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 6 7.000000 350.0000 50.0000
CONOP-CONOP-CONSULT, OT, PHONE 1 1.000000 25.0000 25.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 1 1.000000 50.0000 50.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 1 1.000000 50.0000 50.0000
COUN-H2019HR-INDIVIDUAL/FAMILY THERAPY 2 2.000000 146.6400 73.3200
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 264 1329.250000 66475.0000 50.0094
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 14 18.000000 180.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 138 590.613016 42307.1600 71.6326
OCCT-97530HM-OT SESSION BY OT ASST 31 140.487069 7932.6600 56.4654
PHY-97110-PT SESSION BY LICENSED PT 188 745.016057 62571.2908 83.9865
PHY-97110HM-PT SESSION BY PT ASST 12 60.807920 3698.6200 60.8246
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 358 1578.430593 187106.5688 118.5396
SPL-92508-GROUP SPL SESSION PER CHILD 1 2.000000 27.7600 13.8800
TRAV-TRAVS-Travel by mile 23 937.000000 417.1000 0.4451
Subtotal (Total Children Is Unduplicated) 896 5427.354655 372030.4996 68.5473
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Total 7407.662658 512981.2100 69.2501
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Number of Children (Unduplicated) With at Least One Service 1448
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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 18 19.250000 1046.0700 1046.0700
D 119 143.000000 9550.9900 0.0000
S 116 125.500000 8497.5200 0.0000
H 22 28.500000 2119.7000 0.0000
T 3 36.000000 181.1900 181.1900
1 1.500000 112.5000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 279 353.750000 21507.9700 1227.2600
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 1 44.000000 19.5800 19.5800
6 4.500000 301.0900 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 7 48.500000 320.6700 19.5800
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 126 124.000000 60313.7400 0.0000
T 0 0.000000 0.0000 0.0000
110 103.250000 53879.3400 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 236 227.250000 114193.0800 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 8.500000 1773.5100 1773.5100
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 1 2.000000 114.4000 0.0000
T 0 0.000000 0.0000 0.0000
72 68.000000 8289.0500 0.0000
Other 29 62.500000 4340.7200 678.6800
---------------------------------------------------------
Total 110 141.000000 14517.6800 2452.1900
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
601 595.250000 40794.7200 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 601 595.250000 40794.7200 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
4 6.250000 310.3000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 4 6.250000 310.3000 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 72 72.500000 5031.7300 5031.8900
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
371 765.250000 52841.3200 0.0000
Other 3 5.000000 369.6600 0.0000
---------------------------------------------------------
Total 446 842.750000 58242.7100 5031.8900
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 1 0.500000 19.5600 19.5600
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
495 946.000000 63013.3000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 496 946.500000 63032.8600 19.5600
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
37 108.750000 7726.3800 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 37 108.750000 7726.3800 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 102 111.750000 6347.4900 4963.8000
D 138 143.500000 8443.1200 40.0000
S 1 3.000000 214.3200 0.0000
H 96 101.750000 6755.4200 0.0000
T 21 100.750000 1293.4400 860.4300
574 764.250000 42826.0500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 932 1225.000000 65879.8400 5864.2300
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
698 772.250000 39544.4600 0.0000
Other 16 15.250000 762.5000 0.0000
---------------------------------------------------------
Total 714 787.500000 40306.9600 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 1 1.000000 50.0000 50.0000
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
426 1161.200000 20988.0000 3175.3600
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 427 1162.200000 21038.0000 3225.3600
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 9 16.990400 1274.2800 0.0000
T 0 0.000000 0.0000 0.0000
891 685.067158 46285.8200 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 900 702.057558 47560.1000 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 1 0.655100 46.8000 46.8000
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
133 260.250000 17503.1400 17345.8900
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 134 260.905100 17549.9400 17392.6900