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
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 2 1.000000 37.0000 37.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 1 0.250000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 25 40.500000 1498.5000 37.0000
Subtotal (Total Children Is Unduplicated) 26 41.750000 1535.5000 36.7784
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Screening, Eval, and Assessment,Class #02
ASTE-ASTE-ASSISTIVE TECHNOLOGY EVAL 1 1.000000 48.5000 48.5000
EVAL-96111-DEVELOPMENTAL EVALUATION 1 2.000000 100.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 21 34.500000 2587.5000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 11 21.000000 1575.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 3 7.000000 525.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 14 27.500000 2268.9400 82.5069
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 19 38.000000 2109.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 466 807.641201 59383.3200 73.5269
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 167 293.500000 21550.4500 73.4257
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 67 124.000000 9185.2900 74.0749
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 513 915.500000 50085.1300 54.7080
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 222 392.500000 30334.9600 77.2865
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 13 13.000000 3637.3600 279.7969
MED-99204-OUTPATIENT VISIT, NEW, 45 MINS 3 3.000000 1253.9300 417.9767
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 2 2.000000 111.9700 55.9850
OCTH-97166-OT EVAL MODERATE COMPLEXITY 3 3.000000 153.1500 51.0500
SCREEN-T1023-SCREENING 13 13.000000 650.0000 50.0000
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 15 15.000000 695.7500 46.3833
SPCH-92524-BEHAV & QUAL ANALYSIS OF VOICE AND RES 1 1.000000 51.0500 51.0500
SPCH-92610-EVAL OF ORAL,PHARYNGEAL SWALLOWING FUNC 2 2.000000 97.8800 48.9400
Subtotal (Total Children Is Unduplicated) 909 2716.141201 186404.1800 68.6283
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EI Services,Class #03
COUN-H2019HR-INDIVIDUAL/FAMILY THERAPY 1 4.000000 293.2800 73.3200
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 2 2.000000 50.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 234 1190.650000 59421.4000 49.9067
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 1 1.000000 10.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 28 151.500000 10657.7900 70.3484
PHY-97110-PT SESSION BY LICENSED PT 11 36.000000 2571.8400 71.4400
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 83 444.500000 30585.0500 68.8078
Subtotal (Total Children Is Unduplicated) 353 1829.650000 103589.3600 56.6170
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Total 4587.541201 291529.0400 63.5480
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Number of Children (Unduplicated) With at Least One Service 1206
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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 1 1.000000 71.4400 0.0000
S 5 6.000000 345.7500 0.0000
H 147 187.000000 13528.9100 0.0000
T 0 0.000000 0.0000 0.0000
132 151.500000 8499.1000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 285 345.500000 22445.2000 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 16 17.000000 3460.1400 3460.1400
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
112 105.000000 10402.1700 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 128 122.000000 13862.3100 3460.1400
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
229 372.500000 25032.5000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 229 372.500000 25032.5000 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 206 254.000000 15416.7600 15538.5700
D 11 11.000000 785.8400 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
211 276.000000 17818.0100 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 428 541.000000 34020.6100 15538.5700
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 3 5.500000 355.5000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
431 937.500000 63612.4700 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 434 943.000000 63967.9700 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 69 67.750000 4673.8700 3286.0300
D 31 46.250000 2528.9100 60.0000
S 0 0.000000 0.0000 0.0000
H 115 189.750000 12816.3600 0.0000
T 346 330.250000 19111.8100 12299.7200
197 220.250000 12100.8200 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 758 854.250000 51231.7700 15645.7500
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 44 33.820600 1689.5300 1833.6700
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
354 360.179400 18812.7200 0.0000
Other 199 226.500000 12625.9700 0.0000
---------------------------------------------------------
Total 597 620.500000 33128.2200 1833.6700
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 8 4.650000 234.4000 255.4000
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
323 344.250000 18168.7500 0.0000
Other 27 28.250000 1462.5000 0.0000
---------------------------------------------------------
Total 358 377.150000 19865.6500 255.4000
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 19 38.000000 2850.0000 0.0000
T 0 0.000000 0.0000 0.0000
20 36.641201 2698.0900 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 39 74.641201 5548.0900 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
261 337.000000 22426.7200 6134.1700
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 261 337.000000 22426.7200 6134.1700