CMS/EIP Fiscal Report Statewide
Services beginning 01/01/2018 ending 03/31/2018 Date of Report:05/05/2018 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 5 6.500000 240.5000 37.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 1 1.500000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 29 38.250000 1433.7500 37.4837
Subtotal (Total Children Is Unduplicated) 33 46.250000 1674.2500 36.2000
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Screening, Eval, and Assessment,Class #02
EVAL-96111-DEVELOPMENTAL EVALUATION 1 1.000000 50.0000 50.0000
EXIT-EXIT-EXIT ASSESSMENT 1 1.000000 50.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 21 42.000000 3150.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 12 20.500000 1537.5000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 2 4.500000 337.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 24 35.500000 3256.7100 91.7383
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 19 39.000000 2164.5000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 374 716.290000 52723.9400 73.6070
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 166 315.500000 23343.6100 73.9893
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 114 189.500000 13926.2900 73.4897
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 345 646.000000 35146.2800 54.4060
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 201 328.500000 26024.3900 79.2219
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 22 22.000000 6016.2600 273.4664
MED-99204-OUTPATIENT VISIT, NEW, 45 MINS 1 1.000000 507.0000 507.0000
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 4 4.000000 661.6600 165.4150
PSTH-97161-PT EVAL LOW COMPLEXITY 2 2.000000 102.1000 51.0500
PSTH-97163-PT EVAL HIGH COMPLEXITY 2 2.000000 102.1000 51.0500
SCREEN-T1023-SCREENING 4 4.000000 200.0000 50.0000
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 4 4.000000 204.2000 51.0500
SPCH-92610-EVAL OF ORAL,PHARYNGEAL SWALLOWING FUNC 1 1.000000 44.5500 44.5500
Subtotal (Total Children Is Unduplicated) 786 2379.290000 169548.5900 71.2602
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 2 2.500000 125.0000 50.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 4 2.750000 137.5000 50.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 6 6.000000 300.0000 50.0000
DSTT-DSTT-DIRECT SERVICE COORDINATOR TRAVEL 3 2.750000 0.0000 0.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 187 979.878600 49018.9300 50.0255
OCCT-97530-OT SESSION BY LICENSED OT 14 60.000000 4213.6800 70.2280
PHY-97110-PT SESSION BY LICENSED PT 25 111.250000 7947.7000 71.4400
PHY-97110HM-PT SESSION BY PT ASST 1 1.000000 57.1600 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 97 506.250000 35567.9400 70.2577
Subtotal (Total Children Is Unduplicated) 319 1672.378600 97367.9100 58.2212
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Total 4097.918600 268590.7500 65.5432
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Number of Children (Unduplicated) With at Least One Service 1067
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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 395 433.250000 29719.0400 0.0000
T 6 6.000000 428.6400 0.0000
58 72.250000 4457.5100 0.0000
Other 1 1.000000 50.0000 0.0000
---------------------------------------------------------
Total 460 512.500000 34655.1900 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
11 13.000000 908.2900 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 11 13.000000 908.2900 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 20 19.500000 4121.6900 4121.6900
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
97 103.500000 12641.2500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 117 123.000000 16762.9400 4121.6900
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 5 13.750000 919.0300 919.0300
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 5 13.750000 919.0300 919.0300
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
264 408.500000 28395.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 264 408.500000 28395.0000 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 204 279.500000 16599.4500 16670.0500
D 12 17.000000 1214.6400 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
49 67.500000 4406.0700 74.4000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 265 364.000000 22220.1600 16744.4500
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
420 926.500000 63920.2500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 420 926.500000 63920.2500 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
35 41.250000 2737.7700 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 35 41.250000 2737.7700 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 35 40.750000 2855.0000 1726.7400
D 50 59.250000 3102.7500 0.0000
S 0 0.000000 0.0000 0.0000
H 50 71.250000 4735.5900 0.0000
T 369 400.000000 24566.3000 16747.3600
160 208.250000 12820.7900 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 664 779.500000 48080.4300 18474.1000
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 64 70.228600 3843.9300 1569.5300
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
439 469.150000 24364.3000 0.0000
Other 61 67.500000 3679.0000 0.0000
---------------------------------------------------------
Total 564 606.878600 31887.2300 1569.5300
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 7 7.000000 350.0000 0.0000
T 0 0.000000 0.0000 0.0000
232 253.250000 14195.2100 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 239 260.250000 14545.2100 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 1 2.000000 150.0000 0.0000
T 0 0.000000 0.0000 0.0000
31 46.790000 3409.2500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 32 48.790000 3559.2500 0.0000