CMS/EIP Fiscal Report Statewide
Services beginning 01/01/2019 ending 03/31/2019 Date of Report:05/04/2019 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
TCM-T1017TL-TARGETED CASE MANAGEMENT 5 18.500000 684.5000 37.0000
Subtotal (Total Children Is Unduplicated) 5 18.500000 684.5000 37.0000
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Screening, Eval, and Assessment,Class #02
EVAL-96111-DEVELOPMENTAL EVALUATION 2 6.000000 300.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 11 20.000000 1462.5000 73.1250
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 1.500000 75.0000 50.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 1.000000 75.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 5 8.500000 637.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 11 19.000000 1054.5000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 165 264.253800 19448.5260 73.5979
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 62 103.540033 7537.3100 72.7961
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 40 63.000000 4575.0000 72.6190
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 183 285.000000 15626.0000 54.8281
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 95 136.500000 11154.7600 81.7199
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 3 3.000000 740.7700 246.9233
Subtotal (Total Children Is Unduplicated) 323 911.293833 62686.8660 68.7889
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 2 20.000000 1000.0000 50.0000
INTR-T1013-INTERPRETER 2 3.500000 175.0000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 4 4.000000 40.0000 10.0000
TRAV-TRAVS-Travel by mile 4 60.000000 26.6800 0.4447
Subtotal (Total Children Is Unduplicated) 8 87.500000 1241.6800 14.1906
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Total 1017.293833 64613.0460 63.5146
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Number of Children (Unduplicated) With at Least One Service 331
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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 47 63.500000 3537.5000 3537.5000
D 0 0.000000 0.0000 0.0000
S 1 0.500000 37.5000 0.0000
H 28 38.500000 2682.7500 0.0000
T 3 5.000000 308.2500 308.2500
10 16.500000 1110.7500 0.0000
Other 9 12.500000 859.5000 0.0000
---------------------------------------------------------
Total 98 136.500000 8536.2500 3845.7500
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 5 8.000000 600.0000 600.0000
4 7.500000 562.5000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 9 15.500000 1162.5000 600.0000
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 9 8.500000 1722.1300 1722.1300
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
29 28.500000 2566.2500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 38 37.000000 4288.3800 1722.1300
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
53 68.500000 4533.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 53 68.500000 4533.0000 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 51 81.500000 5413.2000 5413.2000
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
29 46.000000 3078.7500 150.0000
Other 13 18.000000 1350.0000 0.0000
---------------------------------------------------------
Total 93 145.500000 9841.9500 5563.2000
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
59 119.500000 7919.2500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 59 119.500000 7919.2500 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 6 11.000000 756.7500 386.6200
D 13 20.500000 1176.7500 0.0000
S 0 0.000000 0.0000 0.0000
H 22 38.500000 2770.5000 0.0000
T 25 43.500000 2852.8900 2769.3900
22 36.250000 2140.3600 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 88 149.750000 9697.2500 3156.0100
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 2 4.000000 261.0000 324.2600
D 2 3.000000 195.7500 0.0000
S 0 0.000000 0.0000 0.0000
H 2 2.500000 158.2500 158.2500
T 0 0.000000 0.0000 0.0000
34 53.750000 3357.0000 0.0000
Other 1 1.500000 112.5000 0.0000
---------------------------------------------------------
Total 41 64.750000 4084.5000 482.5100
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 0 0.000000 0.0000 0.0000
T 3 4.500000 249.7500 249.7500
43 124.000000 3919.4300 0.0000
Other 2 3.000000 195.7500 0.0000
---------------------------------------------------------
Total 48 131.500000 4364.9300 249.7500
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 7 14.000000 1050.0000 1050.0000
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 7 14.000000 1000.0000 0.0000
T 0 0.000000 0.0000 0.0000
28 49.293833 3494.0360 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 42 77.293833 5544.0360 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 0 0.000000 0.0000 0.0000
66 71.500000 4641.0000 522.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 66 71.500000 4641.0000 522.0000