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: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 3 0.750000 27.7500 37.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 8 4.750000 450.0000 94.7368
TCM-T1017TL-TARGETED CASE MANAGEMENT 20 48.500000 1794.5000 37.0000
Subtotal (Total Children Is Unduplicated) 31 54.000000 2272.2500 42.0787
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Screening, Eval, and Assessment,Class #02
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 2 2.000000 50.6200 25.3100
EVAL-96111-DEVELOPMENTAL EVALUATION 19 35.907400 730.4900 20.3437
EXIT-EXIT-EXIT ASSESSMENT 1 1.000000 50.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 25 46.238000 3505.3500 75.8110
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 12 21.500000 1612.5000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 4 7.500000 562.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 24 37.000000 2775.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 18 35.500000 1970.2500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 326 578.942601 43144.4400 74.5228
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 123 204.279100 15283.4200 74.8164
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 83 140.233400 10449.4200 74.5145
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 323 580.000000 32190.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 219 318.918800 24717.1100 77.5028
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 12 12.000000 3552.8300 296.0692
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 3 3.000000 579.0000 193.0000
NUTR-97803-NUTRITIONAL EVAL, FOLLOW-UP 14 65.000000 3250.0000 50.0000
OCTF-97168-OT RE-EVAL EST PLAN CARE 1 1.000000 51.0500 51.0500
OCTH-97165-OT EVAL LOW COMPLEXITY 3 4.000000 204.2000 51.0500
OCTH-97166-OT EVAL MODERATE COMPLEXITY 3 3.000000 150.0900 50.0300
OCTH-97167-OT EVAL HIGH COMPLEXITY 11 11.000000 561.5500 51.0500
PSTF-97164-PT RE-EVAL EST PLAN CARE 1 1.000000 51.0500 51.0500
PSTH-97161-PT EVAL LOW COMPLEXITY 2 2.000000 751.0500 375.5250
PSTH-97162-PT EVAL MODERATE COMPLEXITY 1 1.000000 51.0500 51.0500
PSTH-97163-PT EVAL HIGH COMPLEXITY 13 13.000000 663.6500 51.0500
SCREEN-T1023-SCREENING 15 15.000000 750.0000 50.0000
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 26 26.000000 1306.2500 50.2404
Subtotal (Total Children Is Unduplicated) 774 2166.019301 148962.8700 68.7726
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 1 1.000000 299.0000 299.0000
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 1 1.000000 50.0000 50.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 1 7.000000 350.0000 50.0000
CONIP-CONIP-CONSULT, ITDS PHONE 4 2.000000 50.0000 25.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 2 2.000000 100.0000 50.0000
CONOP-CONOP-CONSULT, OT, PHONE 5 3.000000 75.0000 25.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 5 5.000000 250.0000 50.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 1 1.000000 50.0000 50.0000
COUN-H2019HR-INDIVIDUAL/FAMILY THERAPY 1 1.000000 73.3200 73.3200
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 1 3.000000 75.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 380 1551.058800 77720.4400 50.1080
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 3 10.000000 100.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 171 598.306437 42045.3700 70.2740
OCCT-97530HM-OT SESSION BY OT ASST 43 159.528342 9097.7800 57.0292
PHY-97110-PT SESSION BY LICENSED PT 247 1315.199607 142819.8451 108.5918
PHY-97110HM-PT SESSION BY PT ASST 20 82.775700 4731.4600 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 409 1686.438068 153845.4600 91.2251
SPL-92508-GROUP SPL SESSION PER CHILD 3 4.000000 699.2000 174.8000
TRAV-TRAVS-Travel by mile 2 162.000000 72.0900 0.4450
Subtotal (Total Children Is Unduplicated) 1101 5595.306954 432503.9651 77.2976
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Total 7815.326255 583739.0851 74.6916
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Number of Children (Unduplicated) With at Least One Service 1745
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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 145 149.000000 8537.4600 8537.4600
D 168 169.500000 9783.0900 0.0000
S 110 120.000000 8458.2000 0.0000
H 113 138.250000 9895.6000 0.0000
T 45 45.000000 2673.0400 2673.0400
27 33.500000 2184.9000 0.0000
Other 1 1.000000 71.4400 0.0000
---------------------------------------------------------
Total 609 656.250000 41603.7300 11210.5000
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 127 125.250000 43599.7500 0.0000
T 0 0.000000 0.0000 0.0000
57 333.000000 18206.0300 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 184 458.250000 61805.7800 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 18 41.500000 3738.4800 3738.4800
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 6 18.000000 1065.7300 0.0000
T 0 0.000000 0.0000 0.0000
91 96.500000 10110.5000 0.0000
Other 43 101.500000 6627.2700 1746.5500
---------------------------------------------------------
Total 158 257.500000 21541.9800 5485.0300
Center 05
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 336.8100 357.2000
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
0 0.000000 0.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 3 5.000000 336.8100 357.2000
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 15 7.500000 535.8000 535.8000
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
845 749.750000 51473.6800 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 860 757.250000 52009.4800 535.8000
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 71 155.000000 9963.7400 9963.7400
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
15 16.250000 757.3000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 86 171.250000 10721.0400 9963.7400
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 74 74.500000 5298.3700 5456.7700
D 6 9.000000 599.6300 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
443 979.000000 67614.8200 71.4600
Other 18 28.500000 2137.5000 0.0000
---------------------------------------------------------
Total 541 1091.000000 75650.3200 5528.2300
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
567 1125.750000 133317.0700 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 567 1125.750000 133317.0700 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
12 33.500000 2393.2400 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 12 33.500000 2393.2400 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 102 121.750000 8194.5400 5602.9300
D 61 71.500000 4417.0400 0.0000
S 0 0.000000 0.0000 0.0000
H 62 66.000000 4261.9600 0.0000
T 58 103.500000 6200.3300 5752.1300
399 579.750000 34438.4700 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 682 942.500000 57512.3400 11355.0600
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 29 29.675000 1410.2500 1845.2500
D 3 3.000000 150.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 4 5.000000 300.0000 300.0000
682 710.052600 36449.0400 637.5000
Other 18 17.250000 859.2500 0.0000
---------------------------------------------------------
Total 736 764.977600 39168.5400 2782.7500
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 4 4.000000 200.0000 270.0000
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
464 650.750000 27150.0900 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 468 654.750000 27350.0900 270.0000
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 4 7.095000 485.7000 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
798 601.503655 39973.3851 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 803 610.598655 40609.0851 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 13 7.000000 479.6900 479.6900
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 4 12.500000 807.2400 807.2400
164 267.250000 18432.6500 18312.4000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 181 286.750000 19719.5800 19599.3300