CMS/EIP Fiscal Report Statewide
Services beginning 10/01/2018 ending 12/31/2018 Date of Report:02/06/2019 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
CASE-CASE-NON-TCM CASE MANAGEMENT 1 0.250000 9.2500 37.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 3 3.500000 129.5000 37.0000
Subtotal (Total Children Is Unduplicated) 4 3.750000 138.7500 37.0000
-----------------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 3 4.000000 214.6700 53.6675
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 2 2.500000 187.5000 75.0000
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 156 249.166667 17726.0000 71.1411
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 61 101.974400 7553.0800 74.0684
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 34 57.000000 4070.6600 71.4151
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 183 296.500000 16336.6500 55.0983
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 78 107.000000 8567.5500 80.0706
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 3 3.000000 504.9000 168.3000
Subtotal (Total Children Is Unduplicated) 273 830.641067 55688.2600 67.0425
-----------------------------------------------------------------------------------------------------------------------
EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 4 13.000000 650.0000 50.0000
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 1 4.000000 285.7600 71.4400
Subtotal (Total Children Is Unduplicated) 5 17.000000 935.7600 55.0447
-----------------------------------------------------------------------------------------------------------------------
Total 851.391067 56762.7700 66.6706
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 280
-----------------------------------------------------------------------------------------------------------------------
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 26 41.000000 2488.6700 2488.6700
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 6 8.000000 600.0000 0.0000
T 3 6.000000 318.1500 318.1500
8 11.000000 678.7500 0.0000
Other 4 5.500000 344.2500 0.0000
---------------------------------------------------------
Total 47 71.500000 4429.8200 2806.8200
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 3 5.500000 412.5000 262.5000
0 0.000000 0.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 3 5.500000 412.5000 262.5000
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 7 7.000000 1289.1700 1289.1700
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
62 57.000000 4097.9100 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 69 64.000000 5387.0800 1289.1700
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 2 3.000000 195.7500 195.7500
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
56 80.000000 5337.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 58 83.000000 5532.7500 195.7500
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 23 34.500000 2000.1700 2000.1700
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
40 64.000000 4216.6200 0.0000
Other 8 11.000000 825.0000 0.0000
---------------------------------------------------------
Total 71 109.500000 7041.7900 2000.1700
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
59 110.500000 7361.2500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 59 110.500000 7361.2500 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 3 4.000000 285.7600 285.7600
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 3 4.000000 285.7600 285.7600
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 6 12.000000 783.0000 375.2800
D 1 2.000000 111.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 23 43.500000 2862.7500 0.0000
T 30 59.000000 3692.8200 3652.8200
26 45.500000 2825.9200 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 86 162.000000 10275.4900 4028.1000
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 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 12.000000 752.5000 0.0000
Other 23 36.000000 2338.0000 0.0000
---------------------------------------------------------
Total 31 48.000000 3090.5000 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 1 1.500000 83.2500 83.2500
39 59.250000 3795.7500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 41 61.750000 3954.0000 158.2500
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 7 14.000000 1050.0000 1050.0000
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 9 18.000000 1350.0000 0.0000
T 0 0.000000 0.0000 0.0000
15 25.641067 1923.0800 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 31 57.641067 4323.0800 1050.0000
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 5 11.000000 636.0000 636.0000
64 63.000000 4032.7500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 69 74.000000 4668.7500 636.0000