CMS/EIP Fiscal Report Statewide
Services beginning 01/01/2017 ending 03/31/2017 Date of Report:05/05/2017 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
TCM-T1017TL-TARGETED CASE MANAGEMENT 3 11.250000 416.2500 37.0000
Subtotal (Total Children Is Unduplicated) 3 11.250000 416.2500 37.0000
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Screening, Eval, and Assessment,Class #02
EVAL-96111-DEVELOPMENTAL EVALUATION 5 9.857000 309.2500 31.3736
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 3 3.500000 262.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 5 7.500000 562.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 6 10.500000 582.7500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 76 120.021934 8855.0100 73.7783
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 36 50.611400 3795.8500 74.9999
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 28 42.862600 3214.6900 74.9999
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 84 132.500000 7353.7500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 65 80.000000 6127.2000 76.5900
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 3 3.000000 912.0000 304.0000
Subtotal (Total Children Is Unduplicated) 195 460.352934 31975.5000 69.4587
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EI Services,Class #03
PHY-97110-PT SESSION BY LICENSED PT 1 1.500000 107.1600 71.4400
Subtotal (Total Children Is Unduplicated) 1 1.500000 107.1600 71.4400
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Total 473.102934 32498.9100 68.6931
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Number of Children (Unduplicated) With at Least One Service 198
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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 3 5.000000 306.7500 306.7500
D 3 4.500000 249.7500 0.0000
S 2 2.500000 187.5000 0.0000
H 10 14.000000 1050.0000 0.0000
T 2 4.000000 211.1600 211.1600
2 3.500000 262.5000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 22 33.500000 2267.6600 517.9100
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 6 6.000000 116.4000 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 6 6.000000 116.4000 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 1 1.000000 239.7000 239.7000
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
29 29.000000 2862.0000 0.0000
Other 1 1.500000 107.1600 0.0000
---------------------------------------------------------
Total 31 31.500000 3208.8600 239.7000
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
46 61.000000 4009.5000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 46 61.000000 4009.5000 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 3 6.000000 450.0000 450.0000
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 5.500000 203.5000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 8 11.500000 653.5000 450.0000
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 1 1.000000 55.5000 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
49 66.000000 4706.2500 0.0000
Other 6 8.000000 600.0000 0.0000
---------------------------------------------------------
Total 56 75.000000 5361.7500 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
68 113.000000 7558.5000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 68 113.000000 7558.5000 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 3 6.000000 315.7100 104.2900
D 4 7.500000 455.2500 0.0000
S 0 0.000000 0.0000 0.0000
H 3 6.000000 450.0000 0.0000
T 1 2.000000 150.0000 150.0000
12 22.500000 1463.2500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 23 44.000000 2834.2100 254.2900
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
29 42.250000 2677.2500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 29 42.250000 2677.2500 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
17 26.500000 1743.7500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 17 26.500000 1743.7500 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 3 3.999667 253.5500 0.0000
D 0 0.000000 0.0000 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
16 22.853267 1663.9800 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 20 28.852934 2067.5300 0.0000