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
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 1 0.500000 18.5000 37.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 6 6.750000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 10 13.750000 508.7500 37.0000
Subtotal (Total Children Is Unduplicated) 17 21.000000 527.2500 25.1071
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Screening, Eval, and Assessment,Class #02
EXIT-EXIT-EXIT ASSESSMENT 4 4.000000 200.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 22 40.000000 3000.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 10 19.500000 1462.5000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 3 5.000000 375.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 27 51.500000 3862.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 20 34.000000 1836.0000 54.0000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 409 764.865333 56178.0000 73.4482
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 175 330.500000 24221.2400 73.2867
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 123 208.000000 15284.0300 73.4809
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 404 731.000000 40119.0700 54.8824
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 217 358.500000 26721.3800 74.5366
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 19 19.000000 5776.0000 304.0000
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 2 2.000000 386.0000 193.0000
OCTH-97165-OT EVAL LOW COMPLEXITY 1 1.000000 51.0500 51.0500
OCTH-97166-OT EVAL MODERATE COMPLEXITY 18 18.000000 871.7000 48.4278
OCTH-97167-OT EVAL HIGH COMPLEXITY 1 1.000000 51.0500 51.0500
PSTF-97164-PT RE-EVAL EST PLAN CARE 1 1.000000 21.0500 21.0500
PSTH-97161-PT EVAL LOW COMPLEXITY 1 1.000000 51.0500 51.0500
SCREEN-T1023-SCREENING 17 19.000000 950.0000 50.0000
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 6 6.000000 291.3000 48.5500
Subtotal (Total Children Is Unduplicated) 881 2614.865333 181708.9200 69.4907
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 2 4.000000 614.6600 153.6650
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 1 1.000000 50.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 182 1000.115000 49713.1000 49.7074
OCCT-97530-OT SESSION BY LICENSED OT 23 85.250000 6067.3600 71.1714
PHY-97110-PT SESSION BY LICENSED PT 23 99.000000 7072.5600 71.4400
PHY-97110HM-PT SESSION BY PT ASST 2 12.000000 685.9200 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 90 395.250000 27473.7000 69.5097
SPL-92508-GROUP SPL SESSION PER CHILD 2 2.000000 27.7600 13.8800
TRAV-TRAVS-Travel by mile 7 8.000000 3.6000 0.4500
Subtotal (Total Children Is Unduplicated) 316 1606.615000 91708.6600 57.0819
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Total 4242.480333 273944.8300 64.5719
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Number of Children (Unduplicated) With at Least One Service 1158
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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 5 5.500000 326.1300 0.0000
S 0 0.000000 0.0000 0.0000
H 399 453.500000 29746.8800 0.0000
T 0 0.000000 0.0000 0.0000
78 98.250000 6030.7000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 482 557.250000 36103.7100 0.0000
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 0 0.000000 0.0000 0.0000
0 0.000000 0.0000 0.0000
Other 1 2.000000 150.0000 0.0000
---------------------------------------------------------
Total 1 2.000000 150.0000 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
116 166.750000 11189.0700 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 116 166.750000 11189.0700 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 1.500000 128.8600 128.8600
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
99 99.500000 12049.5000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 100 101.000000 12178.3600 128.8600
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 4 10.000000 692.9600 692.9600
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 4 10.000000 692.9600 692.9600
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
301 464.500000 32097.7500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 301 464.500000 32097.7500 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 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 4.250000 157.2500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 3 4.250000 157.2500 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 215 298.500000 18807.8900 18854.4100
D 7 9.000000 575.6400 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
38 52.500000 3358.8500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 260 360.000000 22742.3800 18854.4100
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
394 872.000000 60213.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 394 872.000000 60213.0000 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
8 19.000000 1357.3600 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 8 19.000000 1357.3600 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 63 78.000000 5095.7600 2779.4000
D 85 94.000000 5118.7900 51.0500
S 0 0.000000 0.0000 0.0000
H 92 144.750000 9679.6500 0.0000
T 362 384.000000 21670.0600 14721.9000
77 82.000000 5364.4800 605.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 679 782.750000 46928.7400 18157.3500
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 34 31.806600 1627.8300 1209.4100
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
287 292.618400 15166.6700 0.0000
Other 111 135.000000 7701.2500 0.0000
---------------------------------------------------------
Total 432 459.425000 24495.7500 1209.4100
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 16 14.720000 739.0000 1119.0000
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 27 27.000000 1350.0000 0.0000
T 0 0.000000 0.0000 0.0000
232 245.220000 13190.3500 34.9000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 275 286.940000 15279.3500 1153.9000
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
13 15.865333 1139.9000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 18 25.865333 1889.9000 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
98 130.750000 8469.2500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 98 130.750000 8469.2500 0.0000