CMS/EIP Fiscal Report Statewide
Services beginning 07/01/2019 ending 09/30/2019 Date of Report:11/04/2019 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 7 21.750000 804.7500 37.0000
Subtotal (Total Children Is Unduplicated) 7 21.750000 804.7500 37.0000
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Screening, Eval, and Assessment,Class #02
EVAL-96111-DEVELOPMENTAL EVALUATION 1 2.000000 100.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 5 7.961866 597.1399 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 2 2.007866 150.5900 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 3 6.000000 304.0000 50.6667
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 4 7.500000 562.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 6 10.500000 582.7500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 163 254.956533 18724.2400 73.4409
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 66 109.984533 8064.4900 73.3239
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 47 65.500000 4867.9600 74.3200
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 161 260.500000 14457.7500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 76 107.300000 8094.3100 75.4363
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 2 2.000000 608.0000 304.0000
Subtotal (Total Children Is Unduplicated) 300 836.210798 57113.7299 68.3006
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 2 11.000000 550.0000 50.0000
PHY-97110-PT SESSION BY LICENSED PT 1 1.000000 71.4400 71.4400
Subtotal (Total Children Is Unduplicated) 3 12.000000 621.4400 51.7867
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Total 869.960798 58539.9199 67.2903
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Number of Children (Unduplicated) With at Least One Service 307
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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 25 33.000000 1862.8200 1862.8200
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 16 18.500000 1260.7500 0.0000
T 0 0.000000 0.0000 0.0000
3 3.500000 243.0000 0.0000
Other 8 12.500000 859.5000 0.0000
---------------------------------------------------------
Total 52 67.500000 4226.0700 1862.8200
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 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 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 0.500000 202.7400 202.7400
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
32 31.000000 2744.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 33 31.500000 2946.7400 202.7400
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
56 69.000000 4853.2500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 56 69.000000 4853.2500 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 2 2.800000 210.0000 210.0000
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 1 2.000000 150.0000 0.0000
T 0 0.000000 0.0000 0.0000
11 12.250000 510.2500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 14 17.050000 870.2500 210.0000
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 41 62.500000 4024.9600 4024.9600
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
15 21.500000 1515.0000 0.0000
Other 15 21.000000 1575.0000 0.0000
---------------------------------------------------------
Total 71 105.000000 7114.9600 4024.9600
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
90 175.000000 11867.2500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 90 175.000000 11867.2500 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 9 17.000000 1206.7500 651.8100
D 1 2.000000 150.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 16 29.500000 2085.7500 0.0000
T 23 44.000000 2471.9200 2341.9200
18 36.000000 2229.9800 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 67 128.500000 8144.4000 2993.7300
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
40 53.500000 3256.9400 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 40 53.500000 3256.9400 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 0 0.000000 0.0000 0.0000
T 9 16.500000 993.7500 993.7500
28 48.200000 3315.2500 0.0000
Other 1 2.000000 111.0000 0.0000
---------------------------------------------------------
Total 38 66.700000 4420.0000 993.7500
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 10 20.000000 1500.0000 1500.0000
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
29 38.710798 2814.3099 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 44 68.710798 5064.3099 1500.0000
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 711.0000 711.0000
64 69.000000 4502.2500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 69 80.000000 5213.2500 711.0000