CMS/EIP Fiscal Report Statewide
Services beginning 10/01/2017 ending 12/31/2017 Date of Report:02/03/2018 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 20.250000 749.2500 37.0000
Subtotal (Total Children Is Unduplicated) 7 20.250000 749.2500 37.0000
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 3 5.500000 412.5000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 1.500000 112.5000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 2 2.500000 187.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 3 3.500000 300.0000 85.7143
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 5 9.500000 527.2500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 116 203.571067 14619.7300 71.8163
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 38 66.500000 4803.7500 72.2368
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 38 60.000000 4332.5200 72.2087
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 122 202.500000 11103.0000 54.8296
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 54 67.500000 5368.7000 79.5363
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 8 8.000000 2006.4400 250.8050
Subtotal (Total Children Is Unduplicated) 226 630.571067 43773.8900 69.4194
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 1 7.000000 350.0000 50.0000
INTR-T1013-INTERPRETER 3 7.250000 237.5000 32.7586
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 1 3.000000 214.3200 71.4400
Subtotal (Total Children Is Unduplicated) 4 17.250000 801.8200 46.4823
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Total 668.071067 45324.9600 67.8445
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Number of Children (Unduplicated) With at Least One Service 232
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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 3 5.500000 305.2500 305.2500
D 2 1.250000 87.5000 0.0000
S 0 0.000000 0.0000 0.0000
H 4 6.000000 450.0000 0.0000
T 0 0.000000 0.0000 0.0000
15 23.000000 1559.2500 0.0000
Other 4 6.000000 420.7500 0.0000
---------------------------------------------------------
Total 28 41.750000 2822.7500 305.2500
Center 02
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 8 15.000000 1125.0000 1125.0000
0 0.000000 0.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 8 15.000000 1125.0000 1125.0000
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
3 7.000000 225.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 3 7.000000 225.0000 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 6 6.000000 870.6200 870.6200
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
26 27.000000 3399.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 32 33.000000 4269.6200 870.6200
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
51 62.500000 4190.7500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 51 62.500000 4190.7500 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 1 2.000000 150.0000 150.0000
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
0 0.000000 0.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 1 2.000000 150.0000 150.0000
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 45 68.500000 4218.0400 4218.0400
D 1 2.000000 111.0000 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
10 15.000000 921.0000 0.0000
Other 6 9.500000 683.2500 0.0000
---------------------------------------------------------
Total 62 95.000000 5933.2900 4218.0400
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
47 84.500000 5694.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 47 84.500000 5694.0000 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 7 12.500000 862.0000 505.4900
D 4 7.500000 416.2500 0.0000
S 0 0.000000 0.0000 0.0000
H 26 49.500000 3225.0000 0.0000
T 20 37.500000 2075.6100 1942.8600
19 36.500000 2188.7900 150.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 76 143.500000 8767.6500 2598.3500
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 7 6.410810 404.3200 45.0000
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
31 40.589190 2613.2500 0.0000
Other 2 4.000000 261.0000 0.0000
---------------------------------------------------------
Total 40 51.000000 3278.5700 45.0000
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 1 1.000000 75.0000 75.0000
T 1 1.000000 55.5000 55.5000
38 52.250000 3066.7500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 40 54.250000 3197.2500 130.5000
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 11 21.377600 1564.3200 1564.3200
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 2 2.666667 200.0000 0.0000
T 4 8.000000 600.0000 600.0000
20 34.526800 2589.5100 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 37 66.571067 4953.8300 2164.3200
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
4 4.000000 195.2500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 8 12.000000 717.2500 522.0000