CMS/EIP Fiscal Report Statewide
Services beginning 10/01/2015 ending 12/31/2015 Date of Report:02/13/2016 Page: 1
List order: No List
Payclass Filters:MED
Eligibility Filter:Part C (excluding not eligible)
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 12397 34798.50000 1282739.0000 36.8619
Subtotal (Total Children Is Unduplicated) 12397 34798.50000 1282739.0000 36.8619
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 63 100.500000 7537.5000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 37 53.500000 4012.5000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 13 13.500000 1012.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 46 75.000000 5625.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 104 152.500000 8463.7500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 973 1490.392800 111561.9600 74.8541
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 368 570.345800 42700.9300 74.8685
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 315 429.500000 32212.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 1232 1864.500000 103442.7500 55.4802
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 654 963.500000 72262.5000 75.0000
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 15 15.000000 607.5000 40.5000
MED-99204-OUTPATIENT VISIT, NEW, 45 MINS 3 3.000000 171.8100 57.2700
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 5 5.000000 110.7000 22.1400
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 2 2.000000 102.1000 51.0500
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 36 38.000000 1939.9000 51.0500
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 7 8.000000 408.4000 51.0500
PSTH-97001-EVAL BY LICENSED PT, INITIAL 22 22.000000 1123.1000 51.0500
SCREEN-T1023-SCREENING 33 33.000000 1650.0000 50.0000
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 45 46.000000 2348.3000 51.0500
Subtotal (Total Children Is Unduplicated) 2127 5885.238600 397293.7000 67.5068
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EI Services,Class #03
AUD-92633-AUD REHAB POSTLING HEARING LOSS 1 2.000000 143.2200 71.6100
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 11 21.000000 525.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 4521 33458.00000 1672476.0000 49.9873
OCCT-97530-OT SESSION BY LICENSED OT 273 1270.500000 90736.0400 71.4176
OCCT-97530HM-OT SESSION BY OT ASST 96 446.000000 25511.2000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 277 1435.970100 102346.4000 71.2734
PHY-97110HM-PT SESSION BY PT ASST 69 292.000000 16690.7200 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 578 3240.750000 230976.0700 71.2724
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 55 159.000000 9094.8000 57.2000
SPL-92508-GROUP SPL SESSION PER CHILD 5 13.750000 190.8500 13.8800
Subtotal (Total Children Is Unduplicated) 5324 40338.97010 2148690.3000 53.2659
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Total 81022.708700 3828723.0000 47.2549
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Number of Children (Unduplicated) With at Least One Service 13462
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Center 01
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 8 3.000000 118.4400 0.0000
U 0 0.000000 0.0000 0.0000
B 6411 4320.750000 165477.6200 0.0000
P 0 0.000000 0.0000 0.0000
D 1 0.250000 9.2500 0.0000
S 162 143.250000 5532.2500 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
97 53.500000 2100.0400 0.0000
Other 29 33.750000 1903.2500 0.0000
---------------------------------------------------------
Total 6708 4554.500000 175140.8500 0.0000
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 23 24.000000 1528.7200 0.0000
43 70.500000 4728.3700 0.0000
Other 1197 938.500000 38426.0000 0.0000
---------------------------------------------------------
Total 1263 1033.000000 44683.0900 0.0000
Center 03
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 30 11.750000 447.7500 0.0000
U 0 0.000000 0.0000 0.0000
B 140 144.000000 8593.3300 74.0000
P 2372 1391.750000 55470.7500 55626.9920
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 87 86.250000 6018.9700 0.0000
T 0 0.000000 0.0000 0.0000
24 12.750000 484.7500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 2653 1646.500000 71015.5500 55700.9920
Center 04
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 53 66.750000 2469.7500 0.0000
U 0 0.000000 0.0000 0.0000
B 557 746.750000 28346.2500 0.0000
P 1937 2591.500000 102567.8000 102525.4500
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 2109 7514.000000 378460.4800 0.0000
T 0 0.000000 0.0000 0.0000
388 449.500000 21129.4200 0.0000
Other 3 5.750000 402.1700 0.0000
---------------------------------------------------------
Total 5047 11374.250000 533375.8700 102525.4500
Center 05
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 2389 1488.000000 61002.0000 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
1 0.250000 9.2500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 2390 1488.250000 61011.2500 0.0000
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
4034 2660.250000 111854.2900 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 4034 2660.250000 111854.2900 0.0000
Center 07
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 28 18.000000 666.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 70 45.750000 1772.5000 0.0000
P 4189 3087.500000 125200.5000 125069.5000
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
30 55.500000 2748.8200 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 4317 3206.750000 130387.8200 125069.5000
Center 09
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 5 5.000000 198.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 161 184.750000 9966.2500 225.2500
P 4430 4081.000000 171712.3000 282712.0500
D 0 0.000000 0.0000 0.0000
S 1 1.250000 46.2500 46.2500
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
1742 5239.000000 285565.3900 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 6339 9511.000000 467488.1900 282983.5500
Center 10
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 260 166.750000 6169.7500 0.0000
U 0 0.000000 0.0000 0.0000
B 5981 4512.750000 198000.7500 0.0000
P 1 0.500000 18.5000 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
2531 8087.500000 418692.6700 10.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 8773 12767.500000 622881.6700 10.0000
Center 51
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 14 10.750000 415.2500 0.0000
U 0 0.000000 0.0000 0.0000
B 2486 1608.750000 60430.5000 0.0000
P 1 1.000000 71.4400 71.4400
D 5 2.250000 83.2500 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
906 2696.250000 160149.7700 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 3412 4319.000000 221150.2100 71.4400
Center 52
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 22 40.500000 3018.5000 830.0000
U 0 0.000000 0.0000 0.0000
B 1647 1580.000000 78091.7500 13382.5000
P 783 639.500000 23624.0000 23621.5000
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 78 70.750000 4962.5900 2744.5000
643 1119.750000 67837.6800 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 3173 3450.500000 177534.5200 40578.5000
Center 53
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 1 0.500000 18.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 1696 1575.000000 65186.0000 0.0000
P 1575 1553.000000 73303.0000 73367.7500
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
2466 2443.000000 120513.7500 111.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 5738 5571.500000 259021.2500 73478.7500
Center 54
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 4400 3788.750000 165578.7500 0.0000
P 1 2.000000 74.0000 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 2 2.000000 87.0000 0.0000
2924 2893.750000 145830.2000 0.0000
Other 1 0.750000 27.7500 0.0000
---------------------------------------------------------
Total 7328 6687.250000 311597.7000 0.0000
Center 55
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 1 1.000000 37.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 149 134.750000 4985.7500 18.5000
P 1706 1554.500000 62456.5000 80327.7500
D 2 0.500000 18.5000 0.0000
S 29 16.500000 610.5000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
2664 2352.958700 156439.6400 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 4551 4060.208700 224547.8900 80346.2500
Center 57
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 6 6.750000 249.7500 0.0000
U 0 0.000000 0.0000 0.0000
B 3323 3232.500000 128838.2500 0.0000
P 1 1.500000 55.5000 55.5000
D 8 7.750000 343.2500 0.0000
S 0 0.000000 0.0000 0.0000
H 15 18.500000 1023.5000 0.0000
T 4 8.000000 485.7600 485.7600
1816 5417.250000 286036.8400 285923.2500
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 5173 8692.250000 417032.8500 286464.5100