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
Agency Filter:EIP DEI DEIP
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 12317 34661.50000 1277670.0000 36.8614
Subtotal (Total Children Is Unduplicated) 12317 34661.50000 1277670.0000 36.8614
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 62 99.000000 7425.0000 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 43 71.000000 5325.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 97 142.000000 7881.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 873 1323.000000 99082.5000 74.8923
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 347 533.500000 40012.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 270 345.500000 25912.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 1113 1660.500000 92120.7500 55.4777
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 555 809.000000 60675.0000 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
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 3 5.000000 255.2500 51.0500
PSTH-97001-EVAL BY LICENSED PT, INITIAL 7 7.000000 357.3500 51.0500
SCREEN-T1023-SCREENING 33 33.000000 1650.0000 50.0000
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 10 10.000000 510.5000 51.0500
Subtotal (Total Children Is Unduplicated) 1924 5128.500000 347122.3600 67.6850
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EI Services,Class #03
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 6 6.000000 150.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 781 3768.500000 188300.0000 49.9668
OCCT-97530-OT SESSION BY LICENSED OT 15 55.000000 3929.2000 71.4400
PHY-97110-PT SESSION BY LICENSED PT 34 98.750000 7041.7500 71.3089
PHY-97110HM-PT SESSION BY PT ASST 4 18.500000 1057.4600 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 50 291.500000 20454.3300 70.1692
Subtotal (Total Children Is Unduplicated) 877 4238.250000 220932.7400 52.1283
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Total 44028.250000 1845725.1000 41.9214
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Number of Children (Unduplicated) With at Least One Service 12513
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Center 01
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 7 2.000000 47.0000 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 7 5.750000 212.7500 0.0000
---------------------------------------------------------
Total 6685 4525.500000 173378.9100 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 0 0.000000 0.0000 0.0000
0 0.000000 0.0000 0.0000
Other 1194 933.000000 38120.7500 0.0000
---------------------------------------------------------
Total 1194 933.000000 38120.7500 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 552 742.000000 28170.5000 0.0000
P 1778 2464.500000 97816.8000 97974.4500
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
380 443.000000 20888.9200 0.0000
Other 1 0.250000 9.2500 0.0000
---------------------------------------------------------
Total 2764 3716.500000 149355.2200 97974.4500
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
10 6.500000 253.5000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 4297 3157.750000 127892.5000 125069.5000
Center 09
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 3 3.250000 120.2500 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
0 0.000000 0.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 4595 4270.250000 181845.0500 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
15 26.000000 1014.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 6257 4706.000000 205203.0000 0.0000
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 0 0.000000 0.0000 0.0000
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
41 126.000000 8848.4100 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 2546 1747.750000 69777.4100 0.0000
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 77 69.750000 4891.1500 2710.0000
156 147.500000 9777.9700 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 2685 2477.250000 119403.3700 40544.0000
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
556 490.750000 21359.7500 111.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 3828 3619.250000 159867.2500 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
300 247.500000 9372.7500 0.0000
Other 1 0.750000 27.7500 0.0000
---------------------------------------------------------
Total 4704 4041.000000 175140.2500 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
64 64.000000 3201.0500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 1951 1771.250000 71309.3000 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 3322 3231.500000 128801.2500 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 0 0.000000 0.0000 0.0000
2 1.750000 77.7500 50.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 3354 3267.750000 130551.0000 105.5000