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
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 4 2.500000 92.5000 37.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 7 8.500000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 70 136.000000 5032.0000 37.0000
Subtotal (Total Children Is Unduplicated) 74 147.000000 5124.5000 34.8605
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Screening, Eval, and Assessment,Class #02
EXIT-EXIT-EXIT ASSESSMENT 3 3.250000 162.5000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 30 52.000000 3790.0000 72.8846
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 10 18.000000 1305.0000 72.5000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 3 5.500000 412.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 20 32.000000 2350.0000 73.4375
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 17 31.500000 1637.5200 51.9848
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 291 535.249469 39020.5600 72.9016
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 123 225.000000 15929.9300 70.7997
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 94 154.000000 11470.2900 74.4824
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 326 590.000000 32265.3200 54.6870
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 164 254.000000 19037.7800 74.9519
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 15 15.000000 4347.2200 289.8147
OCTH-97165-OT EVAL LOW COMPLEXITY 3 3.000000 153.1500 51.0500
OCTH-97166-OT EVAL MODERATE COMPLEXITY 2 2.000000 102.1000 51.0500
PSTH-97162-PT EVAL MODERATE COMPLEXITY 2 2.000000 102.1000 51.0500
SCREEN-T1023-SCREENING 11 11.000000 550.0000 50.0000
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 9 9.000000 459.4500 51.0500
Subtotal (Total Children Is Unduplicated) 667 1942.499469 133095.4200 68.5176
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 2 2.000000 100.0000 50.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 9 5.500000 275.0000 50.0000
CONIP-CONIP-CONSULT, ITDS PHONE 1 1.000000 25.0000 25.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 8 8.500000 425.0000 50.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 2 2.000000 100.0000 50.0000
COUN-H2019HR-INDIVIDUAL/FAMILY THERAPY 1 1.000000 73.3200 73.3200
DSTT-DSTT-DIRECT SERVICE COORDINATOR TRAVEL 17 20.250000 0.0000 0.0000
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 1 1.000000 25.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 188 937.000000 46710.0000 49.8506
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 10 25.000000 250.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 24 97.250000 6881.1800 70.7576
OCCT-97530HM-OT SESSION BY OT ASST 1 5.000000 286.0000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 29 89.250000 6218.8600 69.6791
PHY-97110HM-PT SESSION BY PT ASST 1 2.000000 114.3200 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 124 570.250000 40458.7800 70.9492
SPL-92508-GROUP SPL SESSION PER CHILD 2 2.000000 23.8800 11.9400
TRAV-TRAVS-Travel by mile 1 22.000000 9.7900 0.4450
Subtotal (Total Children Is Unduplicated) 367 1791.000000 101976.1300 56.9381
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Total 3880.499469 240196.0500 61.8982
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Number of Children (Unduplicated) With at Least One Service 1021
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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 3 4.500000 244.2500 0.0000
S 0 0.000000 0.0000 0.0000
H 259 279.000000 19122.5600 0.0000
T 0 0.000000 0.0000 0.0000
130 154.000000 10097.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 392 437.500000 29463.8100 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
37 37.000000 2502.7400 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 37 37.000000 2502.7400 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 5.000000 974.7200 974.7200
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
57 61.000000 7771.2500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 63 66.000000 8745.9700 974.7200
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 2 5.000000 314.3200 314.3200
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 2 5.000000 314.3200 314.3200
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
219 344.500000 23605.2500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 219 344.500000 23605.2500 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 208 278.000000 16603.1800 16748.3900
D 16 20.000000 1399.7100 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
85 114.750000 7501.2200 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 309 412.750000 25504.1100 16748.3900
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
270 560.000000 38236.5000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 270 560.000000 38236.5000 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
13 40.000000 2857.6000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 13 40.000000 2857.6000 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 5 4.000000 148.0000 0.0000
P 74 88.750000 5944.6800 4588.1800
D 71 95.000000 5030.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 69 106.250000 7090.6100 0.0000
T 409 455.000000 26110.9600 17596.2400
108 120.250000 6857.8200 20.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 736 869.250000 51182.0700 22204.4200
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 25 28.673380 1702.5498 797.6200
D 4 5.000000 295.7500 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
505 539.576620 28492.6002 0.0000
Other 15 18.500000 1065.6300 0.0000
---------------------------------------------------------
Total 549 591.750000 31556.5300 797.6200
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
443 443.000000 21961.4400 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 443 443.000000 21961.4400 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 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
34 41.749469 2931.2100 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 34 41.749469 2931.2100 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
28 32.000000 1334.5000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 28 32.000000 1334.5000 0.0000