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:Program Patients
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 13433 38215.25000 1408566.7500 36.8588
Subtotal (Total Children Is Unduplicated) 13433 38215.25000 1408566.7500 36.8588
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 70 113.000000 8475.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 42 59.000000 4425.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 16 17.000000 1275.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 48 78.500000 5887.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 116 170.500000 9462.7500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 1245 1901.892800 142424.4600 74.8856
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 470 716.345800 53650.9300 74.8953
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 423 589.500000 44212.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 1603 2422.500000 134328.5000 55.4504
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 889 1316.500000 98737.5000 75.0000
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 18 18.000000 729.0000 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 38 38.000000 1900.0000 50.0000
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 45 46.000000 2348.3000 51.0500
Subtotal (Total Children Is Unduplicated) 2730 7564.738600 511712.4500 67.6444
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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 4524 33476.00000 1673376.0000 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 579 3241.750000 231047.5100 71.2725
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) 5328 40357.97010 2149661.7400 53.2649
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Total 86137.958700 4069940.9400 47.2491
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Number of Children (Unduplicated) With at Least One Service 14534
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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 6709 4557.000000 174415.3700 0.0000
P 1 0.250000 9.2500 9.2500
D 1 0.250000 9.2500 0.0000
S 169 148.000000 5822.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
102 56.000000 2192.5400 0.0000
Other 33 38.250000 2153.0000 0.0000
---------------------------------------------------------
Total 7023 4802.750000 184719.8500 9.2500
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
52 87.500000 5964.3700 0.0000
Other 1270 1011.250000 41284.2500 0.0000
---------------------------------------------------------
Total 1345 1122.750000 48777.3400 0.0000
Center 03
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 31 12.500000 475.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 181 197.750000 12338.3300 111.0000
P 2691 1675.250000 67705.2500 67785.9920
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
39 17.750000 669.7500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 3029 1989.500000 87207.8000 67896.9920
Center 04
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 54 67.000000 2479.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 581 793.750000 30122.7500 0.0000
P 2033 2736.500000 108769.5500 108727.2000
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
437 490.000000 23483.9200 0.0000
Other 3 5.750000 402.1700 0.0000
---------------------------------------------------------
Total 5217 11607.000000 543717.8700 108727.2000
Center 05
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 2552 1632.250000 67555.2500 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 2553 1632.500000 67564.5000 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
4201 2789.750000 117948.2900 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 4201 2789.750000 117948.2900 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 71 47.250000 1828.0000 0.0000
P 4612 3543.750000 146345.2500 146214.2500
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 4741 3664.500000 151588.0700 146214.2500
Center 09
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 5 5.000000 198.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 189 225.500000 12554.5000 225.2500
P 4773 4605.000000 198519.5500 309556.8000
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 6710 10075.750000 496883.6900 309828.3000
Center 10
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 270 175.250000 6484.2500 0.0000
U 0 0.000000 0.0000 0.0000
B 6579 5135.000000 228799.2500 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
2535 8101.750000 419362.9200 10.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 9385 13412.500000 654664.9200 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 2583 1681.750000 63177.7500 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
917 2707.750000 160992.7700 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 3520 4403.500000 224740.4600 71.4400
Center 52
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 28 52.500000 3918.5000 1050.0000
U 0 0.000000 0.0000 0.0000
B 1826 1802.500000 89044.2500 15060.0000
P 890 741.250000 27388.7500 27386.2500
D 0 0.000000 0.0000 0.0000
S 1 2.000000 150.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 78 70.750000 4962.5900 2744.5000
656 1144.750000 69712.6800 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 3479 3813.750000 195176.7700 46240.7500
Center 53
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 1 0.500000 18.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 1845 1741.750000 72330.5000 0.0000
P 1726 1715.250000 80961.5000 81026.2500
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
2547 2546.000000 125705.5000 111.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 6119 6003.500000 279016.0000 81137.2500
Center 54
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 4796 4202.250000 184439.2500 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
3007 2985.250000 150584.9500 0.0000
Other 1 0.750000 27.7500 0.0000
---------------------------------------------------------
Total 7807 7192.250000 335212.9500 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 171 162.750000 6021.7500 18.5000
P 2126 2077.250000 85484.2500 103345.7500
D 2 0.500000 18.5000 0.0000
S 52 28.500000 1054.5000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
2723 2467.958700 164144.5800 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 5075 4737.958700 256760.5800 103364.2500
Center 57
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 6 6.750000 249.7500 0.0000
U 0 0.000000 0.0000 0.0000
B 3493 3410.250000 136462.2500 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
1828 5437.250000 287341.8400 287267.2500
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 5355 8890.000000 425961.8500 287808.5100