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
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
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 2 0.750000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 68 136.750000 5059.7500 37.0000
Subtotal (Total Children Is Unduplicated) 69 137.500000 5059.7500 36.7982
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 14 25.238000 1892.8500 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 9 17.000000 1275.0000 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 18 27.500000 2231.4400 81.1433
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 14 25.500000 1292.7700 50.6969
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 283 501.134002 37148.5900 74.1291
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 128 225.000000 16458.6900 73.1497
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 85 154.000000 11257.5200 73.1008
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 271 486.500000 26367.7000 54.1988
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 161 249.999970 18542.4978 74.1700
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 8 8.000000 2432.0000 304.0000
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 2 2.000000 386.0000 193.0000
OCTH-97165-OT EVAL LOW COMPLEXITY 3 3.000000 123.1500 41.0500
OCTH-97166-OT EVAL MODERATE COMPLEXITY 1 1.000000 51.0500 51.0500
PSTH-97162-PT EVAL MODERATE COMPLEXITY 4 4.000000 154.2000 38.5500
SCREEN-T1023-SCREENING 8 9.000000 450.0000 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 3 3.000000 153.1500 51.0500
Subtotal (Total Children Is Unduplicated) 606 1744.871972 120417.6578 69.0123
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EI Services,Class #03
CONPF-CONPF-CONSULT, PT, FACE TO FACE 1 1.000000 50.0000 50.0000
COUN-H2019HR-INDIVIDUAL/FAMILY THERAPY 4 6.000000 439.9200 73.3200
DSTT-DSTT-DIRECT SERVICE COORDINATOR TRAVEL 6 4.250000 0.0000 0.0000
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 3 6.000000 150.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 178 854.750000 42577.5000 49.8128
OCCT-97530-OT SESSION BY LICENSED OT 27 132.000000 9340.0800 70.7582
PHY-97110-PT SESSION BY LICENSED PT 22 64.000000 4380.0000 68.4375
PHY-97110HM-PT SESSION BY PT ASST 2 3.000000 171.4800 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 98 436.750000 30449.8800 69.7192
SPL-92508-GROUP SPL SESSION PER CHILD 2 8.000000 111.0400 13.8800
Subtotal (Total Children Is Unduplicated) 311 1515.750000 87669.9000 57.8393
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Total 3398.121972 213147.3078 62.7250
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Number of Children (Unduplicated) With at Least One Service 928
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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 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 150 173.000000 12021.6900 0.0000
T 0 0.000000 0.0000 0.0000
31 35.500000 2193.1200 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 181 208.500000 14214.8100 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
4 3.250000 150.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 4 3.250000 150.0000 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 1 1.000000 243.9400 243.9400
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 75.500000 7613.5000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 80 76.500000 7857.4400 243.9400
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
224 345.000000 23798.2500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 224 345.000000 23798.2500 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
19 17.750000 732.7500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 19 17.750000 732.7500 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 191 225.000000 13550.4200 13704.9000
D 16 21.000000 1441.9800 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
89 117.500000 7010.9400 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 296 363.500000 22003.3400 13704.9000
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
284 607.000000 41859.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 284 607.000000 41859.0000 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
14 34.000000 2408.5700 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 14 34.000000 2408.5700 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 23 26.250000 1464.0600 1147.9100
D 58 67.500000 3506.5800 40.0000
S 0 0.000000 0.0000 0.0000
H 117 154.000000 9850.3500 0.0000
T 383 401.000000 25838.9500 17007.7900
104 109.000000 5996.8100 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 685 757.750000 46656.7500 18195.7000
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 18 17.906640 821.2202 610.2200
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
456 487.093330 26170.1076 0.0000
Other 30 30.500000 1470.3800 0.0000
---------------------------------------------------------
Total 504 535.499970 28461.7078 610.2200
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
315 328.000000 18079.4700 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 315 328.000000 18079.4700 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 5 10.000000 750.0000 0.0000
T 0 0.000000 0.0000 0.0000
31 48.872002 3665.4000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 36 58.872002 4415.4000 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
51 59.500000 2295.5000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 51 59.500000 2295.5000 0.0000