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
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 13563 39293.00000 1452965.7500 36.9777
Subtotal (Total Children Is Unduplicated) 13563 39293.00000 1452965.7500 36.9777
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 83 123.000000 9225.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 45 63.000000 4725.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 20 22.500000 1687.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 60 85.500000 6412.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 97 143.000000 7936.5000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 904 1357.000000 101737.5000 74.9724
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 425 614.500000 46035.0200 74.9146
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 203 270.000000 20250.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 1153 1664.000000 92110.7700 55.3550
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 497 785.000000 58875.0000 75.0000
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
PSTH-97001-EVAL BY LICENSED PT, INITIAL 5 5.000000 255.2500 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 2 2.000000 102.1000 51.0500
SPCH-92524-BEHAV & QUAL ANALYSIS OF
VOICE AND RES 1 1.000000 51.0500 51.0500
Subtotal (Total Children Is Unduplicated) 2065 5243.500000 354306.9100 67.5707
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EI Services,Class #03
COUN-H2019HR-INDIVIDUAL/FAMILY THERAPY 4 8.000000 586.5600 73.3200
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 8 14.000000 350.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 996 4689.250000 234437.5000 49.9947
OCCT-97530-OT SESSION BY LICENSED OT 22 72.750000 5197.2600 71.4400
PHY-97110-PT SESSION BY LICENSED PT 44 147.500000 10537.4000 71.4400
PHY-97110HM-PT SESSION BY PT ASST 5 36.000000 2057.7600 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 83 282.750000 20178.2200 71.3642
Subtotal (Total Children Is Unduplicated) 1134 5250.250000 273344.7000 52.0632
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Total 49786.750000 2080617.3600 41.7906
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Number of Children (Unduplicated) With at Least One Service 13751
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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 0 0.000000 0.0000 0.0000
D 97 129.000000 9133.7100 0.0000
S 747 742.750000 39788.3500 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
22 13.500000 746.5000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 7704 5312.000000 213671.3100 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 1331 978.000000 41219.2500 0.0000
---------------------------------------------------------
Total 1331 978.000000 41219.2500 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
85 81.000000 5745.8600 0.0000
Other 43 39.250000 1556.2500 0.0000
---------------------------------------------------------
Total 3183 1973.750000 84757.1500 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 61 93.500000 3459.5000 0.0000
P 2963 4216.750000 166891.3900 167217.5600
D 0 0.000000 0.0000 0.0000
S 2 4.250000 157.2500 0.0000
H 0 0.000000 0.0000 0.0000
T 1 1.500000 55.5000 0.0000
185 177.750000 9163.9800 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 3215 4501.250000 180005.1200 167217.5600
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
4446 3193.250000 133407.2500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 4446 3193.250000 133407.2500 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
23 23.000000 921.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 5134 3764.000000 151472.5000 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
0 0.000000 0.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 3926 3895.750000 161900.4800 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
23 20.000000 767.7500 0.0000
Other 1 0.250000 9.2500 0.0000
---------------------------------------------------------
Total 8985 6236.750000 258555.5000 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
18 45.250000 3100.3400 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 2477 1595.500000 63487.0900 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 0 0.000000 0.0000 0.0000
73 64.000000 4426.4200 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 2706 2466.250000 117834.9000 58605.1200
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
451 469.000000 18996.8100 0.0000
Other 1 0.250000 9.2500 0.0000
---------------------------------------------------------
Total 3822 3663.750000 164001.3100 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
275 210.000000 8200.7500 0.0000
Other 4 2.750000 101.7500 0.0000
---------------------------------------------------------
Total 5667 4712.750000 208128.0000 35824.5000
Center 55
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 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
1 0.750000 27.7500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 2883 2595.750000 105710.0000 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 0 0.000000 0.0000 0.0000
1 2.000000 74.0000 0.0000
Other 1 0.750000 27.7500 0.0000
---------------------------------------------------------
Total 3471 3349.500000 133235.2500 34169.5000