CMS/EIP Fiscal Report Statewide
Services beginning 04/01/2017 ending 06/30/2017 Date of Report:08/05/2017 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 3.250000 111.0000 34.1538
Subtotal (Total Children Is Unduplicated) 3 3.250000 111.0000 34.1538
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Screening, Eval, and Assessment,Class #02
EVAL-96111-DEVELOPMENTAL EVALUATION 3 6.407400 320.3700 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 5 10.000000 750.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 2.000000 150.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 2.000000 150.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 3 4.000000 300.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 2 3.000000 166.5000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 107 162.447333 11968.9100 73.6787
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 46 62.861597 4325.7400 68.8137
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 39 56.899100 4128.7725 72.5631
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 129 197.500000 10863.0000 55.0025
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 80 107.000000 8808.1900 82.3195
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 4 4.000000 1044.7700 261.1925
Subtotal (Total Children Is Unduplicated) 242 618.115430 42976.2525 69.5279
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 1 2.000000 100.0000 50.0000
Subtotal (Total Children Is Unduplicated) 1 2.000000 100.0000 50.0000
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Total 623.365430 43187.2525 69.2808
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Number of Children (Unduplicated) With at Least One Service 245
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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 23 35.000000 2098.1100 2098.1100
D 6 6.500000 409.5000 0.0000
S 0 0.000000 0.0000 0.0000
H 12 18.500000 1319.2500 0.0000
T 1 1.500000 83.2500 83.2500
5 8.000000 570.7500 0.0000
Other 3 4.000000 251.2500 0.0000
---------------------------------------------------------
Total 50 73.500000 4732.1100 2181.3600
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 7 6.500000 1360.9600 1360.9600
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 13.000000 1652.2500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 22 19.500000 3013.2100 1360.9600
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 1 1.500000 112.5000 112.5000
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 1 1.500000 112.5000 112.5000
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
66 83.000000 5542.5000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 66 83.000000 5542.5000 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 5.000000 375.0000 375.0000
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
3 2.000000 74.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 6 7.000000 449.0000 375.0000
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 53 74.500000 4757.7100 4757.7100
D 4 5.000000 316.5000 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
40 52.000000 3361.5000 0.0000
Other 4 5.500000 412.5000 0.0000
---------------------------------------------------------
Total 101 137.000000 8848.2100 4757.7100
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
52 85.500000 5847.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 52 85.500000 5847.0000 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 0 0.000000 0.0000 0.0000
D 3 5.500000 305.2500 0.0000
S 0 0.000000 0.0000 0.0000
H 12 23.500000 1616.2500 0.0000
T 11 21.000000 1419.0000 1265.0000
3 6.000000 411.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 29 56.000000 3751.5000 1265.0000
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 2 2.500000 187.5000 187.5000
24 36.500000 2355.7500 0.0000
Other 2 3.000000 233.2500 0.0000
---------------------------------------------------------
Total 28 42.000000 2776.5000 187.5000
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 5 7.000000 408.0000 408.0000
46 71.250000 4886.2500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 51 78.250000 5294.2500 408.0000
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 8.000000 600.0000 600.0000
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 22.115430 1548.4725 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 21 32.115430 2298.4725 600.0000
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 4 8.000000 522.0000 522.0000
0 0.000000 0.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 4 8.000000 522.0000 522.0000