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: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 11 4.000000 148.0000 37.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 13 10.750000 1300.0000 120.9302
TCM-T1017TL-TARGETED CASE MANAGEMENT 67 134.750000 4985.7500 37.0000
Subtotal (Total Children Is Unduplicated) 82 149.500000 6433.7500 43.0351
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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 4 6.000000 2981.0000 496.8333
EXIT-EXIT-EXIT ASSESSMENT 3 4.000000 200.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 28 50.666667 3800.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 17 29.000000 2175.0000 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 28 36.000000 3015.7500 83.7708
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 14 26.500000 1420.7500 53.6132
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 393 673.765503 49946.4604 74.1303
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 193 316.958300 23388.6600 73.7910
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 100 158.908400 11703.3900 73.6487
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 350 600.000000 32928.4700 54.8808
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 215 322.000000 24989.9200 77.6084
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 14 14.000000 4256.0000 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) 844 2360.788670 171321.6104 72.5697
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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 25 975.000000 434.0100 0.4451
Subtotal (Total Children Is Unduplicated) 898 5465.354655 372047.4096 68.0738
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Total 7975.643325 549802.7700 68.9352
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Number of Children (Unduplicated) With at Least One Service 1638
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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 19 20.750000 1129.3200 1129.3200
D 130 158.000000 10568.7400 0.0000
S 123 137.500000 9329.2700 0.0000
H 30 39.500000 2944.7000 0.0000
T 3 36.000000 181.1900 181.1900
2 3.000000 195.7500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 307 394.750000 24348.9700 1310.5100
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 128 126.000000 61841.7400 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 238 229.250000 115721.0800 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
80 75.500000 9080.5500 0.0000
Other 29 62.500000 4340.7200 678.6800
---------------------------------------------------------
Total 118 148.500000 15309.1800 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
645 655.750000 44834.9700 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 645 655.750000 44834.9700 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
5 6.750000 328.8000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 5 6.750000 328.8000 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
415 826.750000 57228.3200 0.0000
Other 5 8.500000 632.1600 0.0000
---------------------------------------------------------
Total 492 907.750000 62892.2100 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
571 1080.000000 72098.0500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 572 1080.500000 72117.6100 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 110 127.250000 7048.7500 5532.2700
D 144 154.500000 9092.6200 40.0000
S 1 3.000000 214.3200 0.0000
H 97 103.750000 6905.4200 0.0000
T 21 100.750000 1293.4400 860.4300
612 836.500000 47178.1400 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 985 1325.750000 71732.6900 6432.7000
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
734 824.000000 42883.9600 0.0000
Other 17 16.750000 875.0000 0.0000
---------------------------------------------------------
Total 751 840.750000 43758.9600 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
454 1234.700000 23352.6600 3500.5200
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 455 1235.700000 23402.6600 3550.5200
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 16 30.990400 2324.2800 0.0000
T 0 0.000000 0.0000 0.0000
901 701.047825 47434.3700 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 917 732.038225 49758.6500 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