CMS/EIP Fiscal Report Statewide
Services beginning 07/01/2016 ending 09/30/2016 Date of Report:10/31/2016 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 13672 40005.75000 1479079.0000 36.9717
Subtotal (Total Children Is Unduplicated) 13672 40005.75000 1479079.0000 36.9717
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 97 141.500000 10612.5000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 59 78.000000 5850.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 18 26.500000 1987.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 49 82.500000 6187.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 146 219.000000 12126.7500 55.3733
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 1040 1549.500000 116106.4600 74.9316
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 546 785.000000 58875.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 329 470.500000 35225.0000 74.8672
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 1383 2010.000000 111487.0000 55.4662
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 621 957.000000 71662.5000 74.8824
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 35 35.000000 1417.5000 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 3 3.000000 153.1500 51.0500
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 38 38.000000 1939.9000 51.0500
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 4 4.000000 204.2000 51.0500
PSTH-97001-EVAL BY LICENSED PT, INITIAL 9 9.000000 459.4500 51.0500
SCREEN-T1023-SCREENING 70 75.000000 3750.0000 50.0000
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 38 38.000000 1939.9000 51.0500
SPCH-92524-BEHAV & QUAL ANALYSIS OF
VOICE AND RES 2 2.000000 102.1000 51.0500
Subtotal (Total Children Is Unduplicated) 2365 6531.500000 440368.9200 67.4223
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EI Services,Class #03
COUN-H2019HR-INDIVIDUAL/FAMILY THERAPY 18 47.000000 3446.0400 73.3200
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 14 18.750000 468.7500 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 5070 32630.75000 1631253.5000 49.9913
OCCT-97530-OT SESSION BY LICENSED OT 259 1233.250000 88103.3800 71.4400
OCCT-97530HM-OT SESSION BY OT ASST 106 522.500000 29698.2000 56.8387
PHY-97110-PT SESSION BY LICENSED PT 259 1310.500000 93532.8700 71.3719
PHY-97110HM-PT SESSION BY PT ASST 54 303.000000 17319.4800 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 546 3069.750000 219160.0600 71.3935
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 3 6.500000 371.8000 57.2000
SPL-92508-GROUP SPL SESSION PER CHILD 3 5.000000 69.4000 13.8800
Subtotal (Total Children Is Unduplicated) 5787 39147.00000 2083423.4800 53.2205
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Total 85684.250000 4002871.4000 46.7165
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Number of Children (Unduplicated) With at Least One Service 14791
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Center 01
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 46 20.500000 758.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 7748 5148.000000 190947.0200 0.2500
P 0 0.000000 0.0000 0.0000
D 9 9.000000 516.4200 0.0000
S 513 505.250000 28721.0800 0.0000
H 0 0.000000 0.0000 0.0000
T 9 7.000000 418.5400 400.0400
94 133.000000 8363.1300 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 8419 5822.750000 229724.6900 400.2900
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
17 17.000000 993.9300 0.0000
Other 1658 1135.750000 46650.7500 0.0000
---------------------------------------------------------
Total 1675 1152.750000 47644.6800 0.0000
Center 03
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 201 133.500000 6193.9400 0.0000
P 3614 2248.500000 92913.2500 30577.5000
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 46 44.500000 3158.6900 0.0000
T 0 0.000000 0.0000 0.0000
5 6.750000 419.9400 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 3866 2433.250000 102685.8200 30577.5000
Center 04
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 1 2.000000 74.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 819 1168.000000 46835.5000 0.0000
P 2521 3606.750000 141984.1600 142034.2400
D 0 0.000000 0.0000 0.0000
S 1 2.000000 74.0000 0.0000
H 1957 7114.500000 359070.0400 210.0000
T 0 0.000000 0.0000 0.0000
514 682.000000 34551.8200 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 5813 12575.250000 582589.5200 142244.2400
Center 05
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 2352 1598.250000 66439.5000 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 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 2352 1598.250000 66439.5000 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
4658 3304.000000 137889.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 4658 3304.000000 137889.0000 0.0000
Center 07
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 7 3.750000 138.7500 0.0000
U 0 0.000000 0.0000 0.0000
B 359 251.000000 9485.5000 0.0000
P 4853 3636.000000 146864.2500 146836.5000
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
16 41.250000 2033.2500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 5235 3932.000000 158521.7500 146836.5000
Center 09
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 231 218.500000 8561.2500 12.5000
P 4332 4149.000000 174411.2700 173586.2500
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
1945 6007.000000 336463.7200 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 6508 10374.500000 519436.2400 173598.7500
Center 10
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 1235 961.750000 45407.5000 0.0000
P 3909 2834.500000 125446.2500 125446.2500
D 0 0.000000 0.0000 0.0000
S 1 0.500000 18.5000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
2035 6895.250000 353463.5300 0.0000
Other 1 0.250000 9.2500 0.0000
---------------------------------------------------------
Total 7181 10692.250000 524345.0300 125446.2500
Center 51
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 1 1.000000 75.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 2850 1762.250000 67726.0000 0.0000
P 1 1.000000 51.0500 51.0500
D 10 4.500000 166.5000 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
819 2440.500000 145540.9400 0.0000
Other 2 2.500000 187.5000 0.0000
---------------------------------------------------------
Total 3683 4211.750000 213746.9900 51.0500
Center 52
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 10 17.500000 1255.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 2224 2144.750000 90675.5000 0.0000
P 446 524.250000 30886.3300 29972.1300
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 4.500000 271.6400 271.6400
763 1547.750000 93031.7900 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 3445 4238.750000 216120.7600 30243.7700
Center 53
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 2 2.250000 83.2500 0.0000
U 0 0.000000 0.0000 0.0000
B 1785 1691.500000 78371.5400 0.0000
P 1900 1749.000000 77322.0000 77272.0000
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
1903 1974.500000 96593.2500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 5590 5417.250000 252370.0400 77272.0000
Center 54
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 2 2.000000 100.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 5067 4110.500000 171562.0000 0.0000
P 720 749.750000 39423.2500 39423.2500
D 0 0.000000 0.0000 0.0000
S 21 21.500000 1187.5000 0.0000
H 0 0.000000 0.0000 0.0000
T 1 1.000000 37.0000 0.0000
2014 2041.750000 104460.2900 0.0000
Other 2 1.750000 64.7500 0.0000
---------------------------------------------------------
Total 7827 6928.250000 316834.7900 39423.2500
Center 55
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 146 112.750000 4171.7500 3496.5000
P 2234 2149.000000 86767.2500 88112.2500
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
3204 2974.750000 186021.9800 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 5584 5236.500000 276960.9800 91608.7500
Center 57
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 3447 3386.000000 134692.2500 0.0000
P 9 7.500000 447.0000 0.0000
D 0 0.000000 0.0000 0.0000
S 4 8.000000 400.0000 400.0000
H 0 0.000000 0.0000 0.0000
T 1 3.000000 214.3200 214.3200
1256 4362.250000 221808.0400 221808.0400
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 4717 7766.750000 357561.6100 222422.3600