CMS/EIP Fiscal Report Statewide
Services beginning 07/01/2017 ending 09/30/2017 Date of Report:11/05/2017 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 7 12.500000 462.5000 37.0000
Subtotal (Total Children Is Unduplicated) 7 12.500000 462.5000 37.0000
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 4 6.500000 487.5000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 4 7.000000 401.5200 57.3600
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 1.500000 112.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 2 3.000000 171.0000 57.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 3 4.500000 249.7500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 114 182.886369 13518.4600 73.9173
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 53 90.422300 6691.6700 74.0046
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 37 61.500000 4570.0000 74.3089
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 106 173.000000 9479.1500 54.7928
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 59 87.500000 6307.5400 72.0862
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 2 2.000000 608.0000 304.0000
Subtotal (Total Children Is Unduplicated) 206 619.808669 42597.0900 68.7262
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EI Services,Class #03
OCCT-97530-OT SESSION BY LICENSED OT 1 0.750000 53.5800 71.4400
OCCT-97530HM-OT SESSION BY OT ASST 1 3.500000 200.2000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 1 4.000000 285.7600 71.4400
Subtotal (Total Children Is Unduplicated) 3 8.250000 539.5400 65.3988
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Total 640.558669 43599.1300 68.0642
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Number of Children (Unduplicated) With at Least One Service 213
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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 7 10.500000 623.2500 623.2500
D 1 2.000000 111.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 12 15.000000 1125.0000 0.0000
T 2 3.500000 262.5000 262.5000
5 8.500000 549.7500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 27 39.500000 2671.5000 885.7500
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 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
24 24.000000 2189.7500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 24 24.000000 2189.7500 0.0000
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
63 80.500000 5482.2500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 63 80.500000 5482.2500 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
4 4.000000 148.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 4 4.000000 148.0000 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 38 55.500000 3175.9800 3175.9800
D 5 6.500000 419.2500 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
27 40.500000 2656.7500 0.0000
Other 17 26.500000 1987.5000 0.0000
---------------------------------------------------------
Total 87 129.000000 8239.4800 3175.9800
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
55 111.000000 7525.5000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 55 111.000000 7525.5000 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 0 0.000000 0.0000 0.0000
D 9 15.500000 860.2500 0.0000
S 0 0.000000 0.0000 0.0000
H 19 34.500000 2412.0000 0.0000
T 23 45.000000 3180.0000 2820.0000
7 13.500000 810.4600 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 58 108.500000 7262.7100 2820.0000
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 1 2.000000 150.0000 150.0000
14 23.000000 1564.5100 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 15 25.000000 1714.5100 150.0000
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
23 32.500000 1977.5000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 23 32.500000 1977.5000 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 8 15.500000 1162.5000 1162.5000
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
42 63.058669 4664.4300 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 52 82.558669 6126.9300 1162.5000
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 2 4.000000 261.0000 261.0000
0 0.000000 0.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 2 4.000000 261.0000 261.0000