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Provider Demographic Information - ARM/IND ODP ICDTEN TEST ENTITY

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PROVIDER DEMOGRAPHIC INFORMATION Supporting line for group header


Name:	ARM/IND ODP ICDTEN TEST ENTITY
Address:	16TH N. 3RD ST. CAMP HILL, PA 17011
Phone:	(814) 555-1000
Web Site:	N/A

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PROVIDER CERTIFICATION INFORMATION Supporting line for group header

Click here to view Provider Certification Information

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PROVIDER'S PARENT/ REGIONAL OFFICE Supporting line for group header


Type:	Corporate Office
Name:	Arm/Ind ODP ICDTen Test Entity
Address:	1243 NTH 10TH ST Indiana, PA 16565
Phone:	(814) 555-1000

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PROVIDER SERVICES AND RATES Supporting line for group header


County : Allegheny
\|Service Name / Level	\|Rate

Art Therapy	$11.00 - $15.00 / 15 min.
Art Therapy-ECS	$11.00 - $16.00 / 15 min.
CPS < 25% Cmnty 1:1-FBS 1:1 (Level 3 Enhanced)	$11.00 / 15 min.
CPS < 25% Cmnty 1:1-FBS 1:1 (Level 3 Enhanced) RN	$11.00 - $25.00 / 15 min.
Companion Services (Basic Staff Support)	$11.00 / 15 min.
Companion Services (Level 1)	$11.00 / 15 min.
Companion Services (Level 2)	$11.00 - $15.00 / 15 min.
Equine Assisted Therapy	$11.00 / 15 min.
Fmly/Crgvr Spprt-Cnslng-no Participant Present	$11.00 - $75.00 / 15 min.
Life Sharing-1 per-Inelig-Unlic	$11.00 / 1 Day
Music Therapy	$11.00 - $20.00 / 15 min.
Music Therapy-ECS	$11.00 - $21.00 / 15 min.
Supports Coordination	$11.00 - $21.00 / 15 min.
Transportation(Zone 1)-Trip	$4.00 - $11.00 / Trip

County : Armstrong/Indiana
\|Service Name / Level	\|Rate

Companion Services (Level 1)	$11.00 / 15 min.
Companion Services (Level 2)	$11.00 - $15.00 / 15 min.
Supports Coordination	$11.00 - $21.00 / 15 min.

County : Beaver
\|Service Name / Level	\|Rate

Companion Services (Level 1)	$11.00 / 15 min.
Companion Services (Level 2)	$11.00 - $15.00 / 15 min.
Supports Coordination	$11.00 - $21.00 / 15 min.

County : Bedford/Somerset
\|Service Name / Level	\|Rate

Companion Services (Level 1)	$11.00 / 15 min.
Companion Services (Level 2)	$11.00 - $15.00 / 15 min.
Supports Coordination	$11.00 - $21.00 / 15 min.

County : Berks
\|Service Name / Level	\|Rate

Companion Services (Level 1)	$11.00 / 15 min.
Companion Services (Level 2)	$11.00 - $15.00 / 15 min.
Supports Coordination	$11.00 - $21.00 / 15 min.

County : Blair
\|Service Name / Level	\|Rate

Companion Services (Level 1)	$11.00 / 15 min.
Companion Services (Level 2)	$11.00 - $15.00 / 15 min.
Supports Coordination	$11.00 - $21.00 / 15 min.

County : Bradford/Sullivan
\|Service Name / Level	\|Rate

Companion Services (Level 1)	$11.00 / 15 min.
Companion Services (Level 2)	$11.00 - $15.00 / 15 min.
Supports Coordination	$11.00 - $21.00 / 15 min.

County : Bucks
\|Service Name / Level	\|Rate

Companion Services (Level 1)	$11.00 / 15 min.
Companion Services (Level 2)	$11.00 - $15.00 / 15 min.
Supports Coordination	$11.00 - $21.00 / 15 min.

County : Butler
\|Service Name / Level	\|Rate

Companion Services (Level 1)	$11.00 / 15 min.
Companion Services (Level 2)	$11.00 - $15.00 / 15 min.
Supports Coordination	$11.00 - $21.00 / 15 min.

County : Cambria
\|Service Name / Level	\|Rate

Companion Services (Level 1)	$11.00 / 15 min.
Companion Services (Level 2)	$11.00 - $15.00 / 15 min.
Supports Coordination	$11.00 - $21.00 / 15 min.

County : Cameron/Elk
\|Service Name / Level	\|Rate

Companion Services (Level 1)	$11.00 / 15 min.
Companion Services (Level 2)	$11.00 - $15.00 / 15 min.
Supports Coordination	$11.00 - $21.00 / 15 min.

County : Carbon/Monroe/Pike
\|Service Name / Level	\|Rate

Companion Services (Level 1)	$11.00 / 15 min.
Companion Services (Level 2)	$11.00 - $15.00 / 15 min.
Supports Coordination	$11.00 - $21.00 / 15 min.

County : Centre
\|Service Name / Level	\|Rate

Companion Services (Level 1)	$11.00 / 15 min.
Companion Services (Level 2)	$11.00 - $15.00 / 15 min.
Supports Coordination	$11.00 - $21.00 / 15 min.

County : Chester
\|Service Name / Level	\|Rate

Companion Services (Level 1)	$11.00 / 15 min.
Companion Services (Level 2)	$11.00 - $15.00 / 15 min.
Supports Coordination	$11.00 - $21.00 / 15 min.

County : Clarion
\|Service Name / Level	\|Rate

Companion Services (Level 1)	$11.00 / 15 min.
Companion Services (Level 2)	$11.00 - $15.00 / 15 min.
Supports Coordination	$11.00 - $21.00 / 15 min.

County : Clearfield/Jefferson
\|Service Name / Level	\|Rate

Companion Services (Level 1)	$11.00 / 15 min.
Companion Services (Level 2)	$11.00 - $15.00 / 15 min.
Supports Coordination	$11.00 - $21.00 / 15 min.

County : Columbia/Montour/Snyder/Union
\|Service Name / Level	\|Rate

Companion Services (Level 1)	$11.00 / 15 min.
Companion Services (Level 2)	$11.00 - $15.00 / 15 min.
Supports Coordination	$11.00 - $21.00 / 15 min.

County : Crawford
\|Service Name / Level	\|Rate

Companion Services (Level 1)	$11.00 / 15 min.
Companion Services (Level 2)	$11.00 - $15.00 / 15 min.
Supports Coordination	$11.00 - $21.00 / 15 min.

County : Cumberland/Perry
\|Service Name / Level	\|Rate

Companion Services (Level 1)	$11.00 / 15 min.
Companion Services (Level 2)	$11.00 - $15.00 / 15 min.
Supports Coordination	$11.00 - $21.00 / 15 min.

County : Dauphin
\|Service Name / Level	\|Rate

Companion Services (Level 1)	$11.00 / 15 min.
Companion Services (Level 2)	$11.00 - $15.00 / 15 min.
Supports Coordination	$11.00 - $21.00 / 15 min.

County : Delaware
\|Service Name / Level	\|Rate

Companion Services (Level 1)	$11.00 / 15 min.
Companion Services (Level 2)	$11.00 - $15.00 / 15 min.
Supports Coordination	$11.00 - $21.00 / 15 min.

County : Erie
\|Service Name / Level	\|Rate

Companion Services (Level 1)	$11.00 / 15 min.
Companion Services (Level 2)	$11.00 - $15.00 / 15 min.
Supports Coordination	$11.00 - $21.00 / 15 min.

County : Fayette
\|Service Name / Level	\|Rate

Companion Services (Level 1)	$11.00 / 15 min.
Companion Services (Level 2)	$11.00 - $15.00 / 15 min.
Supports Coordination	$11.00 - $21.00 / 15 min.

County : Forest/Warren
\|Service Name / Level	\|Rate

Companion Services (Level 1)	$11.00 / 15 min.
Companion Services (Level 2)	$11.00 - $15.00 / 15 min.
Supports Coordination	$11.00 - $21.00 / 15 min.

County : Franklin/Fulton
\|Service Name / Level	\|Rate

Companion Services (Level 1)	$11.00 / 15 min.
Companion Services (Level 2)	$11.00 - $15.00 / 15 min.
Supports Coordination	$11.00 - $21.00 / 15 min.

County : Greene
\|Service Name / Level	\|Rate

Companion Services (Level 1)	$11.00 / 15 min.
Companion Services (Level 2)	$11.00 - $15.00 / 15 min.
Supports Coordination	$11.00 - $21.00 / 15 min.

County : Huntingdon/Mifflin/Juniata
\|Service Name / Level	\|Rate

Companion Services (Level 1)	$11.00 / 15 min.
Companion Services (Level 2)	$11.00 - $15.00 / 15 min.
Supports Coordination	$11.00 - $21.00 / 15 min.

County : Lackawanna/Susquehanna
\|Service Name / Level	\|Rate

Companion Services (Level 1)	$11.00 / 15 min.
Companion Services (Level 2)	$11.00 - $15.00 / 15 min.
Supports Coordination	$11.00 - $21.00 / 15 min.

County : Lancaster
\|Service Name / Level	\|Rate

Companion Services (Level 1)	$11.00 / 15 min.
Companion Services (Level 2)	$11.00 - $15.00 / 15 min.
Supports Coordination	$11.00 - $21.00 / 15 min.

County : Lawrence
\|Service Name / Level	\|Rate

Companion Services (Level 1)	$11.00 / 15 min.
Companion Services (Level 2)	$11.00 - $15.00 / 15 min.
Supports Coordination	$11.00 - $21.00 / 15 min.

County : Lebanon
\|Service Name / Level	\|Rate

Companion Services (Level 1)	$11.00 / 15 min.
Companion Services (Level 2)	$11.00 - $15.00 / 15 min.
Supports Coordination	$11.00 - $21.00 / 15 min.

County : Lehigh
\|Service Name / Level	\|Rate

Companion Services (Level 1)	$11.00 / 15 min.
Companion Services (Level 2)	$11.00 - $15.00 / 15 min.
Supports Coordination	$11.00 - $21.00 / 15 min.

County : Luzerne/Wyoming
\|Service Name / Level	\|Rate

Companion Services (Level 1)	$11.00 / 15 min.
Companion Services (Level 2)	$11.00 - $15.00 / 15 min.
Supports Coordination	$11.00 - $21.00 / 15 min.

County : Lycoming/Clinton
\|Service Name / Level	\|Rate

Companion Services (Level 1)	$11.00 / 15 min.
Companion Services (Level 2)	$11.00 - $15.00 / 15 min.
Supports Coordination	$11.00 - $21.00 / 15 min.

County : McKean
\|Service Name / Level	\|Rate

Companion Services (Level 1)	$11.00 / 15 min.
Companion Services (Level 2)	$11.00 - $15.00 / 15 min.
Supports Coordination	$11.00 - $21.00 / 15 min.

County : Mercer
\|Service Name / Level	\|Rate

Companion Services (Level 1)	$11.00 / 15 min.
Companion Services (Level 2)	$11.00 - $15.00 / 15 min.
Supports Coordination	$11.00 - $21.00 / 15 min.

County : Montgomery
\|Service Name / Level	\|Rate

Companion Services (Level 1)	$11.00 / 15 min.
Companion Services (Level 2)	$11.00 - $15.00 / 15 min.
Supports Coordination	$11.00 - $21.00 / 15 min.

County : Northampton
\|Service Name / Level	\|Rate

Companion Services (Level 1)	$11.00 / 15 min.
Companion Services (Level 2)	$11.00 - $15.00 / 15 min.
Supports Coordination	$11.00 - $21.00 / 15 min.

County : Northumberland
\|Service Name / Level	\|Rate

Companion Services (Level 1)	$11.00 / 15 min.
Companion Services (Level 2)	$11.00 - $15.00 / 15 min.
Supports Coordination	$11.00 - $21.00 / 15 min.

County : Philadelphia
\|Service Name / Level	\|Rate

Companion Services (Level 1)	$11.00 / 15 min.
Companion Services (Level 2)	$11.00 - $15.00 / 15 min.
Supports Coordination	$11.00 - $21.00 / 15 min.

County : Potter
\|Service Name / Level	\|Rate

Companion Services (Level 1)	$11.00 / 15 min.
Companion Services (Level 2)	$11.00 - $15.00 / 15 min.
Supports Coordination	$11.00 - $21.00 / 15 min.

County : Schuylkill
\|Service Name / Level	\|Rate

Companion Services (Level 1)	$11.00 / 15 min.
Companion Services (Level 2)	$11.00 - $15.00 / 15 min.
Supports Coordination	$11.00 - $21.00 / 15 min.

County : Tioga
\|Service Name / Level	\|Rate

Companion Services (Level 1)	$11.00 / 15 min.
Companion Services (Level 2)	$11.00 - $15.00 / 15 min.
Supports Coordination	$11.00 - $21.00 / 15 min.

County : Venango
\|Service Name / Level	\|Rate

Companion Services (Level 1)	$11.00 / 15 min.
Companion Services (Level 2)	$11.00 - $15.00 / 15 min.
Supports Coordination	$11.00 - $21.00 / 15 min.

County : Washington
\|Service Name / Level	\|Rate

Companion Services (Level 1)	$11.00 / 15 min.
Companion Services (Level 2)	$11.00 - $15.00 / 15 min.
Supports Coordination	$11.00 - $21.00 / 15 min.

County : Wayne
\|Service Name / Level	\|Rate

Companion Services (Level 1)	$11.00 / 15 min.
Companion Services (Level 2)	$11.00 - $15.00 / 15 min.
Supports Coordination	$11.00 - $21.00 / 15 min.

County : Westmoreland
\|Service Name / Level	\|Rate

Companion Services (Level 1)	$11.00 / 15 min.
Companion Services (Level 2)	$11.00 - $15.00 / 15 min.
Supports Coordination	$11.00 - $21.00 / 15 min.

County : York/Adams
\|Service Name / Level	\|Rate

Companion Services (Level 1)	$11.00 / 15 min.
Companion Services (Level 2)	$11.00 - $15.00 / 15 min.
Supports Coordination	$11.00 - $21.00 / 15 min.

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