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:Program Patients
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 14545 43326.25000 1601698.0000 36.9683
Subtotal (Total Children Is Unduplicated) 14545 43326.25000 1601698.0000 36.9683
-----------------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 106 158.500000 11887.5000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 71 95.500000 7162.5000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 19 27.500000 2062.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 61 101.000000 7575.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 166 253.500000 14041.5000 55.3905
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 1308 1949.000000 146068.9600 74.9456
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 689 977.000000 73245.7500 74.9701
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 419 608.000000 45537.5000 74.8972
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 1751 2548.500000 141346.0000 55.4624
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 814 1253.500000 93900.0000 74.9103
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 42 42.000000 1701.0000 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 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 78 84.000000 4200.0000 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) 2966 8200.000000 553809.4200 67.5377
-----------------------------------------------------------------------------------------------------------------------
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 5071 32636.75000 1631553.5000 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 547 3070.750000 219231.5000 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) 5789 39154.00000 2083794.9200 53.2205
-----------------------------------------------------------------------------------------------------------------------
Total 90680.250000 4239302.3400 46.7500
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 15700
-----------------------------------------------------------------------------------------------------------------------
Center 01
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 46 20.500000 758.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 8067 5400.250000 200337.2700 0.2500
P 0 0.000000 0.0000 0.0000
D 9 9.000000 516.4200 0.0000
S 563 556.750000 31366.0800 0.0000
H 0 0.000000 0.0000 0.0000
T 9 7.000000 418.5400 400.0400
105 146.750000 9190.8800 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 8799 6140.250000 242587.6900 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 1802 1268.750000 51729.0000 0.0000
---------------------------------------------------------
Total 1819 1285.750000 52722.9300 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 219 151.250000 7116.6900 0.0000
P 3901 2506.250000 104487.0000 35805.7500
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
6 7.750000 475.4400 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 4172 2709.750000 115237.8200 35805.7500
Center 04
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 1 2.000000 74.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 845 1204.000000 48563.0000 0.0000
P 2687 3911.250000 154721.9100 154855.5200
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
558 731.500000 37084.5700 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 6049 12965.250000 599587.5200 155065.5200
Center 05
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 2587 1827.000000 76518.2500 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
0 0.000000 0.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 2587 1827.000000 76518.2500 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
4793 3437.000000 144130.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 4793 3437.000000 144130.0000 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 362 253.250000 9568.7500 0.0000
P 5344 4199.500000 173183.2500 173155.5000
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 5729 4497.750000 184924.0000 173155.5000
Center 09
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 2 4.000000 261.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 235 223.500000 8746.2500 12.5000
P 4610 4555.750000 194699.2700 193359.0000
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
1981 6055.500000 340101.2200 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 6828 10838.750000 543807.7400 193371.5000
Center 10
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 1345 1092.750000 52386.5000 0.0000
P 4197 3160.250000 142287.7500 142287.7500
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 7579 11149.000000 548165.5300 142287.7500
Center 51
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 1 1.000000 75.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 2926 1815.500000 69836.0000 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
833 2455.000000 146589.4400 0.0000
Other 2 2.500000 187.5000 0.0000
---------------------------------------------------------
Total 3773 4279.500000 216905.4900 51.0500
Center 52
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 12 21.500000 1555.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 2409 2363.500000 99719.5000 0.0000
P 489 605.750000 36223.0800 35308.8800
D 0 0.000000 0.0000 0.0000
S 3 6.000000 450.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 2 4.500000 271.6400 271.6400
777 1574.250000 94869.2900 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 3692 4575.500000 233089.0100 35580.5200
Center 53
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 3 4.250000 194.2500 0.0000
U 0 0.000000 0.0000 0.0000
B 1849 1760.750000 81803.2900 0.0000
P 2057 1940.000000 86268.7500 86218.7500
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 1 1.000000 37.0000 0.0000
1962 2045.500000 100029.2500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 5872 5751.500000 268332.5400 86218.7500
Center 54
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 2 2.000000 100.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 5484 4547.750000 190091.0000 0.0000
P 748 789.750000 42218.5000 42218.5000
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
2045 2084.250000 107501.5400 0.0000
Other 2 1.750000 64.7500 0.0000
---------------------------------------------------------
Total 8303 7448.000000 341200.2900 42218.5000
Center 55
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 166 131.000000 4847.0000 4070.0000
P 2528 2559.750000 105138.5000 106483.5000
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
3266 3097.750000 194502.4200 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 5960 5788.500000 304487.9200 110553.5000
Center 57
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 3605 3589.000000 143617.2500 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
1266 4379.250000 222927.0400 222796.5400
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 4885 7986.750000 367605.6100 223410.8600