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
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 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
EVAL-96111-DEVELOPMENTAL EVALUATION 1 1.000000 1328.0000 1328.0000
EXIT-EXIT-EXIT ASSESSMENT 3 4.000000 200.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 22 42.000000 3150.0000 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 1 1.000000 75.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 25 31.000000 2640.7500 85.1855
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 11 20.000000 1060.0000 53.0000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 265 464.994403 34722.1404 74.6722
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 138 229.500000 16974.6200 73.9635
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 45 72.000000 5400.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 245 427.000000 23326.9700 54.6299
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 160 242.000000 19007.7600 78.5445
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
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 3 3.000000 153.1500 51.0500
PSTH-97001-EVAL BY LICENSED PT, INITIAL 6 7.000000 4550.0000 650.0000
SCREEN-T1023-SCREENING 9 9.000000 450.0000 50.0000
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 4 4.000000 204.2000 51.0500
Subtotal (Total Children Is Unduplicated) 575 1600.494403 119680.5904 74.7773
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 1 1.000000 50.0000 50.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 4 2.750000 137.5000 50.0000
COUN-H2019HR-INDIVIDUAL/FAMILY THERAPY 2 2.000000 146.6400 73.3200
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 204 1039.500000 51987.5000 50.0120
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 11 15.000000 150.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 22 81.500000 6908.0200 84.7610
PHY-97110-PT SESSION BY LICENSED PT 34 123.750000 20046.1700 161.9893
PHY-97110HM-PT SESSION BY PT ASST 3 29.500000 1909.0600 64.7139
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 106 504.250000 114754.9700 227.5755
TRAV-TRAVS-Travel by mile 2 78.000000 34.7200 0.4451
Subtotal (Total Children Is Unduplicated) 354 1877.250000 196124.5800 104.4744
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Total 3607.744403 321554.4204 89.1289
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Number of Children (Unduplicated) With at Least One Service 908
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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 54 74.500000 5355.8500 0.0000
S 107 111.000000 7410.0200 0.0000
H 22 28.500000 2119.7000 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 183 214.000000 14885.5700 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 126 124.000000 60313.7400 0.0000
T 0 0.000000 0.0000 0.0000
105 98.500000 53601.4400 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 231 222.500000 113915.1800 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 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
71 67.000000 8238.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 79 75.500000 10011.5100 1773.5100
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
213 336.750000 22745.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 213 336.750000 22745.0000 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 0.250000 9.2500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 1 0.250000 9.2500 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
152 200.250000 13645.1000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 224 272.750000 18676.8300 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 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
287 537.500000 37689.7500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 287 537.500000 37689.7500 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 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
430 490.000000 28014.2800 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 788 950.750000 51068.0700 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
599 631.250000 32484.1400 0.0000
Other 16 15.250000 762.5000 0.0000
---------------------------------------------------------
Total 615 646.500000 33246.6400 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
290 296.250000 15562.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 290 296.250000 15562.0000 0.0000
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
18 17.754003 1170.0504 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 27 34.744403 2444.3304 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 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
5 4.250000 157.2500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 5 4.250000 157.2500 0.0000