CMS/EIP Fiscal Report Statewide
Services beginning 10/01/2016 ending 12/31/2016 Date of Report:02/04/2017 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 13643 39426.00000 1457886.7500 36.9778
Subtotal (Total Children Is Unduplicated) 13643 39426.00000 1457886.7500 36.9778
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 89 134.000000 10050.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 51 75.000000 5625.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 24 28.500000 2137.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 71 105.000000 7875.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 126 194.000000 10767.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 1012 1519.000000 113813.5000 74.9266
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 466 686.000000 51397.5200 74.9235
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 295 427.000000 32000.0000 74.9415
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 1291 1899.500000 105181.0200 55.3730
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 613 968.000000 72526.0000 74.9236
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 29 29.000000 1174.5000 40.5000
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 8 8.000000 177.1200 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 36 36.000000 1837.8000 51.0500
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 6 6.000000 306.3000 51.0500
PSTH-97001-EVAL BY LICENSED PT, INITIAL 34 34.000000 1735.7000 51.0500
SCREEN-T1023-SCREENING 60 69.000000 3450.0000 50.0000
SPCH-92521-EVAL OF SPEECH FLUENCY 2 2.000000 102.1000 51.0500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 29 29.000000 1480.4500 51.0500
SPCH-92524-BEHAV & QUAL ANALYSIS OF
VOICE AND RES 2 2.000000 102.1000 51.0500
Subtotal (Total Children Is Unduplicated) 2246 6254.000000 421891.7600 67.4595
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 3 7.360000 764.3700 103.8546
COUN-H2019HR-INDIVIDUAL/FAMILY THERAPY 4 8.000000 586.5600 73.3200
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 9 24.000000 600.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 5551 37619.50000 1880781.0000 49.9948
OCCT-97530-OT SESSION BY LICENSED OT 297 1578.000000 112548.0000 71.3232
OCCT-97530HM-OT SESSION BY OT ASST 131 616.500000 35263.8000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 314 1580.750000 112908.3900 71.4271
PHY-97110HM-PT SESSION BY PT ASST 79 398.500000 22778.2600 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 589 3300.250000 235710.4200 71.4220
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 7 11.500000 657.8000 57.2000
SPL-92508-GROUP SPL SESSION PER CHILD 10 32.000000 444.1600 13.8800
Subtotal (Total Children Is Unduplicated) 6407 45176.36000 2403042.7600 53.1925
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Total 90856.360000 4282821.2700 47.1384
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Number of Children (Unduplicated) With at Least One Service 14674
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Center 01
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 44 20.750000 767.7500 0.0000
U 0 0.000000 0.0000 0.0000
B 6794 4406.000000 163235.0000 0.0000
P 24 23.500000 1412.4000 1412.4000
D 145 191.000000 12810.3400 0.0000
S 765 770.750000 41888.3500 0.0000
H 0 0.000000 0.0000 0.0000
T 3 3.000000 214.3200 214.3200
25 16.000000 885.2500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 7800 5431.000000 221213.4100 1626.7200
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
7 7.000000 414.3200 0.0000
Other 1333 982.000000 41519.2500 0.0000
---------------------------------------------------------
Total 1340 989.000000 41933.5700 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 129 83.250000 3603.5000 0.0000
P 2879 1725.000000 70680.0500 25762.0500
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 47 45.250000 3171.4900 0.0000
T 0 0.000000 0.0000 0.0000
87 83.000000 5888.7400 0.0000
Other 43 39.250000 1556.2500 0.0000
---------------------------------------------------------
Total 3185 1975.750000 84900.0300 25762.0500
Center 04
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 3 7.500000 277.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 62 94.750000 3505.7500 0.0000
P 3122 4348.500000 171766.1400 172092.3100
D 0 0.000000 0.0000 0.0000
S 3 9.250000 407.2500 0.0000
H 2091 7744.500000 391214.2700 357.2000
T 1 1.500000 55.5000 0.0000
329 532.000000 34023.0200 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 5611 12738.000000 601249.4300 172449.5100
Center 05
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 2346 1548.500000 63232.2500 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 2346 1548.500000 63232.2500 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
6947 5507.000000 255593.1300 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 6947 5507.000000 255593.1300 0.0000
Center 07
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 6 4.750000 175.7500 0.0000
U 0 0.000000 0.0000 0.0000
B 213 141.500000 5387.2500 0.0000
P 4892 3594.750000 144988.5000 144951.5000
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
35 62.000000 2882.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 5146 3803.000000 153433.5000 144951.5000
Center 09
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 106 102.250000 4699.7500 101.7500
P 3820 3793.500000 157200.7300 156731.4800
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
2008 6066.500000 338693.5200 0.0000
Other 81 115.500000 8637.5000 0.0000
---------------------------------------------------------
Total 6015 10077.750000 509231.5000 156833.2300
Center 10
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 73 44.000000 1628.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 8713 6034.500000 251044.5000 0.0000
P 0 0.000000 0.0000 0.0000
D 0 0.000000 0.0000 0.0000
S 175 138.000000 5106.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
2880 9599.250000 494377.5100 0.0000
Other 1 0.250000 9.2500 0.0000
---------------------------------------------------------
Total 11842 15816.000000 752165.2600 0.0000
Center 51
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 50 32.750000 1211.7500 0.0000
U 0 0.000000 0.0000 0.0000
B 2404 1514.250000 59054.7500 0.0000
P 0 0.000000 0.0000 0.0000
D 5 3.250000 120.2500 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
855 2560.750000 153989.0400 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 3314 4111.000000 214375.7900 0.0000
Center 52
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 9 12.000000 750.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 893 912.500000 46314.7500 175.7500
P 1621 1371.500000 59648.3900 58429.3700
D 20 18.000000 1264.4800 0.0000
S 41 45.000000 2450.0000 0.0000
H 49 43.250000 2980.8600 0.0000
T 1 2.000000 142.8800 142.8800
639 1326.000000 79289.6000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 3273 3730.250000 192840.9600 58748.0000
Center 53
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 6 4.250000 157.2500 0.0000
U 0 0.000000 0.0000 0.0000
B 550 529.750000 25699.5000 0.0000
P 2814 2660.500000 119138.5000 119138.5000
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
1883 1952.000000 95287.3100 0.0000
Other 1 0.250000 9.2500 0.0000
---------------------------------------------------------
Total 5254 5146.750000 240291.8100 119138.5000
Center 54
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 3 2.000000 74.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 4712 3815.000000 163983.5000 50.0000
P 672 682.750000 35758.7500 35774.5000
D 0 0.000000 0.0000 0.0000
S 1 0.250000 9.2500 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
2420 2415.110000 122086.0400 85228.7100
Other 4 2.750000 101.7500 0.0000
---------------------------------------------------------
Total 7812 6917.860000 322013.2900 121053.2100
Center 55
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 21 15.000000 555.0000 0.0000
P 2861 2580.000000 105127.2500 105127.2500
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
2995 2772.500000 169257.5100 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 5877 5367.500000 274939.7600 105127.2500
Center 57
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 3 3.000000 111.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 2550 2410.500000 98379.2500 0.0000
P 914 929.750000 34513.7500 34169.5000
D 2 3.500000 129.5000 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 1 -2.000000 -100.0000 -100.0000
1287 4351.500000 222346.3300 222172.1700
Other 1 0.750000 27.7500 0.0000
---------------------------------------------------------
Total 4758 7697.000000 355407.5800 256241.6700