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
Agency Filter:EIP DEI DEIP
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 1 0.250000 9.2500 37.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 5 5.250000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 26 55.000000 1979.5000 35.9909
Subtotal (Total Children Is Unduplicated) 32 60.500000 1988.7500 32.8719
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Screening, Eval, and Assessment,Class #02
EVAL-96111-DEVELOPMENTAL EVALUATION 1 2.000000 100.0000 50.0000
EXIT-EXIT-EXIT ASSESSMENT 1 1.000000 50.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 16 30.500000 2057.5000 67.4590
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 4 10.000000 580.0000 58.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 3 4.500000 337.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 23 34.000000 2556.2700 75.1844
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 18 32.000000 1776.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 308 558.287204 41491.6503 74.3195
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 145 260.500000 19332.5000 74.2131
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 90 156.000000 11660.0000 74.7436
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 327 626.500000 34274.0200 54.7071
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 197 296.500000 23385.1800 78.8708
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 12 12.000000 3648.0000 304.0000
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 1 1.000000 193.0000 193.0000
OCTH-97165-OT EVAL LOW COMPLEXITY 2 2.000000 102.1000 51.0500
OCTH-97166-OT EVAL MODERATE COMPLEXITY 4 4.000000 204.2000 51.0500
PSTH-97162-PT EVAL MODERATE COMPLEXITY 1 1.000000 51.0500 51.0500
PSTH-97163-PT EVAL HIGH COMPLEXITY 3 3.000000 153.1500 51.0500
SCREEN-T1023-SCREENING 13 13.000000 650.0000 50.0000
SPCH-92522-EVAL OF SPCH SOUND PROD 1 1.000000 51.0500 51.0500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 9 9.000000 459.4500 51.0500
Subtotal (Total Children Is Unduplicated) 720 2057.787204 143112.6203 69.5469
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EI Services,Class #03
COUN-H2019HR-INDIVIDUAL/FAMILY THERAPY 2 5.000000 366.6000 73.3200
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 5 11.000000 275.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 225 1238.750000 61912.5000 49.9798
OCCT-97530-OT SESSION BY LICENSED OT 23 112.500000 8037.0000 71.4400
PHY-97110-PT SESSION BY LICENSED PT 16 42.500000 2886.2000 67.9106
PHY-97110HM-PT SESSION BY PT ASST 1 2.000000 114.3200 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 68 322.500000 22078.7000 68.4611
SPL-92508-GROUP SPL SESSION PER CHILD 2 4.000000 55.5200 13.8800
Subtotal (Total Children Is Unduplicated) 329 1738.250000 95725.8400 55.0702
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Total 3856.537204 240827.2103 62.4465
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Number of Children (Unduplicated) With at Least One Service 1015
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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 0 0.000000 0.0000 0.0000
D 9 14.500000 834.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 76 95.000000 6667.3500 0.0000
T 0 0.000000 0.0000 0.0000
21 25.500000 1629.5400 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 106 135.000000 9130.8900 0.0000
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 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
1 0.500000 0.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 1 0.500000 0.0000 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 16.500000 2763.9100 2763.9100
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
79 76.000000 8527.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 97 92.500000 11290.9100 2763.9100
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 3.000000 214.3200 214.3200
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 3.000000 214.3200 214.3200
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
206 326.000000 22266.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 206 326.000000 22266.0000 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
8 8.250000 305.2500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 8 8.250000 305.2500 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 209 253.500000 15005.4000 14993.4400
D 7 10.000000 633.0000 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
89 112.500000 7399.7300 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 305 376.000000 23038.1300 14993.4400
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
377 802.750000 54775.7500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 377 802.750000 54775.7500 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
16 43.500000 3090.8100 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 16 43.500000 3090.8100 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 11 12.500000 664.3600 547.6800
D 67 90.500000 4794.7500 0.0000
S 0 0.000000 0.0000 0.0000
H 191 233.250000 15546.7400 0.0000
T 224 260.250000 16903.8000 11651.2500
194 201.750000 10970.8900 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 687 798.250000 48880.5400 12198.9300
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 42 39.450000 1923.7500 1188.7500
D 10 12.000000 661.0000 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
589 623.300000 31927.1000 0.0000
Other 27 24.250000 1179.2500 0.0000
---------------------------------------------------------
Total 668 699.000000 35691.1000 1188.7500
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 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
465 498.250000 27036.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 465 498.250000 27036.0000 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 0 0.000000 0.0000 0.0000
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 7 14.000000 1000.0000 0.0000
T 0 0.000000 0.0000 0.0000
30 46.287204 3522.2603 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 37 60.287204 4522.2603 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 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
14 13.250000 585.2500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 14 13.250000 585.2500 0.0000