CMS/EIP Fiscal Report Statewide
Services beginning 04/01/2018 ending 06/30/2018 Date of Report:08/10/2018 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
Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 8 13.878000 1040.8500 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 2 3.000000 225.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 2 2.500000 177.5000 71.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 1 1.500000 112.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 9 16.000000 888.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 138 225.834268 16465.6900 72.9105
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 56 82.216667 6015.6000 73.1676
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 48 73.000000 5341.3000 73.1685
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 111 193.500000 10555.2900 54.5493
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 76 98.500000 7649.3400 77.6583
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 8 8.000000 2432.0000 304.0000
OCTH-97165-OT EVAL LOW COMPLEXITY 1 1.000000 51.0500 51.0500
OCTH-97166-OT EVAL MODERATE COMPLEXITY 1 1.000000 51.0500 51.0500
SCREEN-T1023-SCREENING 1 1.000000 50.0000 50.0000
Subtotal (Total Children Is Unduplicated) 257 720.928935 51055.1700 70.8186
-----------------------------------------------------------------------------------------------------------------------
EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 3 4.000000 200.0000 50.0000
Subtotal (Total Children Is Unduplicated) 3 4.000000 200.0000 50.0000
-----------------------------------------------------------------------------------------------------------------------
Total 724.928935 51255.1700 70.7037
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 258
-----------------------------------------------------------------------------------------------------------------------
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 4 6.000000 329.0000 329.0000
D 1 1.500000 112.5000 0.0000
S 0 0.000000 0.0000 0.0000
H 9 11.000000 795.7500 0.0000
T 8 12.500000 674.7500 674.7500
7 9.500000 576.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 29 40.500000 2488.0000 1003.7500
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 4 7.500000 562.5000 562.5000
0 0.000000 0.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 4 7.500000 562.5000 562.5000
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
36 57.000000 4152.5000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 36 57.000000 4152.5000 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 3 3.000000 536.8400 536.8400
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 29.000000 3987.5000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 34 32.000000 4524.3400 536.8400
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
50 62.000000 4308.7500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 50 62.000000 4308.7500 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 73 105.000000 6757.6000 6307.6000
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
5 7.500000 562.5000 0.0000
Other 18 27.500000 2033.2500 0.0000
---------------------------------------------------------
Total 96 140.000000 9353.3500 6307.6000
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
71 140.500000 9426.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 71 140.500000 9426.0000 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 1 1.000000 75.0000 75.0000
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 1.000000 75.0000 75.0000
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 8 11.500000 732.0200 437.2900
D 7 12.500000 693.7500 0.0000
S 0 0.000000 0.0000 0.0000
H 27 49.500000 3400.5000 0.0000
T 19 36.000000 2297.3700 2194.3700
2 4.000000 192.9200 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 63 113.500000 7316.5600 2631.6600
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 1 1.500000 112.5000 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 18.500000 1206.5000 0.0000
Other 6 9.000000 626.2500 0.0000
---------------------------------------------------------
Total 20 29.000000 1945.2500 0.0000
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 2 3.000000 195.7500 195.7500
31 47.500000 3167.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 34 51.500000 3437.7500 270.7500
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 6 12.000000 900.0000 900.0000
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 4 8.000000 600.0000 0.0000
T 0 0.000000 0.0000 0.0000
16 16.428935 1232.1700 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 26 36.428935 2732.1700 900.0000
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 4 8.000000 522.0000 522.0000
5 6.000000 411.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 9 14.000000 933.0000 522.0000