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: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 3 0.750000 27.7500 37.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 8 4.750000 450.0000 94.7368
TCM-T1017TL-TARGETED CASE MANAGEMENT 23 59.750000 2210.7500 37.0000
Subtotal (Total Children Is Unduplicated) 34 65.250000 2688.5000 41.2031
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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 24 45.764400 1039.7400 22.7194
EXIT-EXIT-EXIT ASSESSMENT 1 1.000000 50.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 28 49.738000 3767.8500 75.7540
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 29 44.500000 3337.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 24 46.000000 2553.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 402 698.964535 51999.4500 74.3950
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 159 254.890500 19079.2700 74.8528
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 111 183.096000 13664.1100 74.6281
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 407 712.500000 39543.7500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 284 398.918800 30844.3100 77.3198
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 15 15.000000 4464.8300 297.6553
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) 969 2626.372235 180938.3700 68.8929
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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 248 1316.699607 142927.0051 108.5494
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) 1102 5596.806954 432611.1251 77.2961
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Total 8288.429189 616237.9951 74.3492
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Number of Children (Unduplicated) With at Least One Service 1943
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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 148 154.000000 8844.2100 8844.2100
D 171 174.000000 10032.8400 0.0000
S 112 122.500000 8645.7000 0.0000
H 123 152.250000 10945.6000 0.0000
T 47 49.000000 2884.2000 2884.2000
29 37.000000 2447.4000 0.0000
Other 1 1.000000 71.4400 0.0000
---------------------------------------------------------
Total 631 689.750000 43871.3900 11728.4100
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 133 131.250000 43716.1500 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 190 464.250000 61922.1800 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 19 42.500000 3978.1800 3978.1800
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
120 125.500000 12972.5000 0.0000
Other 44 103.000000 6734.4300 1746.5500
---------------------------------------------------------
Total 189 289.000000 24750.8400 5724.7300
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
891 810.750000 55483.1800 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 906 818.250000 56018.9800 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 74 161.000000 10413.7400 10413.7400
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
20 21.750000 960.8000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 94 182.750000 11374.5400 10413.7400
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 7 10.000000 655.1300 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
492 1045.000000 72321.0700 71.4600
Other 24 36.500000 2737.5000 0.0000
---------------------------------------------------------
Total 597 1166.000000 81012.0700 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
635 1238.750000 140875.5700 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 635 1238.750000 140875.5700 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 105 127.750000 8510.2500 5707.2200
D 65 79.000000 4872.2900 0.0000
S 0 0.000000 0.0000 0.0000
H 65 72.000000 4711.9600 0.0000
T 59 105.500000 6350.3300 5902.1300
411 602.250000 35901.7200 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 705 986.500000 60346.5500 11609.3500
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
711 752.302600 39126.2900 637.5000
Other 18 17.250000 859.2500 0.0000
---------------------------------------------------------
Total 765 807.227600 41845.7900 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
481 677.250000 28893.8400 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 485 681.250000 29093.8400 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 7 11.094667 739.2500 0.0000
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 2 4.000000 300.0000 0.0000
T 0 0.000000 0.0000 0.0000
814 624.356922 41637.3651 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 823 639.451589 42676.6151 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