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:Program Patients
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 14585 43060.75000 1592170.0000 36.9750
Subtotal (Total Children Is Unduplicated) 14585 43060.75000 1592170.0000 36.9750
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 103 159.000000 11925.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 61 91.500000 6862.5000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 31 40.500000 3037.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 86 130.500000 9787.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 152 236.000000 13098.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 1360 2045.000000 153263.5000 74.9455
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 597 873.000000 65422.5200 74.9399
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 390 566.500000 42462.5000 74.9559
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 1696 2497.000000 138259.0200 55.3701
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 775 1214.500000 91013.5000 74.9391
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 33 33.000000 1336.5000 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 67 76.000000 3800.0000 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) 2902 8082.500000 546162.7600 67.5735
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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 5555 37635.50000 1881581.0000 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 590 3305.250000 236067.6200 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) 6412 45197.36000 2404199.9600 53.1934
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Total 96340.610000 4542532.7200 47.1508
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Number of Children (Unduplicated) With at Least One Service 15633
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Center 01
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 47 22.250000 823.2500 0.0000
U 0 0.000000 0.0000 0.0000
B 7156 4688.000000 173690.0000 0.0000
P 24 23.500000 1412.4000 1412.4000
D 170 229.000000 15250.8400 0.0000
S 845 866.000000 46629.1000 0.0000
H 0 0.000000 0.0000 0.0000
T 3 3.000000 214.3200 214.3200
29 19.500000 1033.2500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 8274 5851.250000 239053.1600 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 1523 1137.750000 48287.7500 0.0000
---------------------------------------------------------
Total 1530 1144.750000 48702.0700 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 131 85.500000 3686.7500 0.0000
P 3149 1984.250000 82946.8000 32646.3000
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 48 45.250000 1778.2500 0.0000
---------------------------------------------------------
Total 3462 2243.250000 97472.0300 32646.3000
Center 04
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 3 7.500000 277.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 65 102.500000 3792.5000 0.0000
P 3369 4763.750000 189685.8900 190178.4500
D 0 0.000000 0.0000 0.0000
S 3 9.250000 407.2500 0.0000
H 2093 7747.500000 391364.2700 357.2000
T 1 1.500000 55.5000 0.0000
350 551.500000 35276.0200 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 5884 13183.500000 620858.9300 190535.6500
Center 05
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 2524 1708.000000 70729.7500 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 2524 1708.000000 70729.7500 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
7132 5707.500000 265075.8800 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 7132 5707.500000 265075.8800 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 228 154.500000 5868.2500 0.0000
P 5447 4189.250000 172834.7500 172797.7500
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 0 0.000000 0.0000 0.0000
38 65.000000 3069.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 5719 4413.500000 181947.7500 172797.7500
Center 09
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 117 120.000000 5470.5000 101.7500
P 4057 4152.000000 174454.2300 173984.9800
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
2009 6068.500000 338843.5200 0.0000
Other 121 170.500000 12762.5000 0.0000
---------------------------------------------------------
Total 6304 10511.000000 531530.7500 174086.7300
Center 10
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 77 47.250000 1748.2500 0.0000
U 0 0.000000 0.0000 0.0000
B 9325 6685.500000 281593.2500 0.0000
P 0 0.000000 0.0000 0.0000
D 0 0.000000 0.0000 0.0000
S 189 151.000000 5587.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
2881 9601.250000 494451.5100 0.0000
Other 1 0.250000 9.2500 0.0000
---------------------------------------------------------
Total 12473 16485.250000 783389.2600 0.0000
Center 51
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 53 36.000000 1332.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 2532 1619.750000 63368.7500 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
878 2586.250000 155862.5400 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 3468 4245.250000 220683.5400 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 949 1010.500000 52482.5000 175.7500
P 1791 1566.500000 67865.1400 66646.1200
D 20 18.000000 1264.4800 0.0000
S 43 49.000000 2750.0000 0.0000
H 49 43.250000 2980.8600 0.0000
T 1 2.000000 142.8800 142.8800
650 1346.500000 80827.1000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 3512 4047.750000 209062.9600 66964.7500
Center 53
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 6 4.250000 157.2500 0.0000
U 0 0.000000 0.0000 0.0000
B 554 535.750000 26091.0000 0.0000
P 2931 2805.000000 125711.0000 125711.0000
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
1918 1995.250000 97330.3100 0.0000
Other 1 0.250000 9.2500 0.0000
---------------------------------------------------------
Total 5410 5340.500000 249298.8100 125711.0000
Center 54
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 3 2.000000 74.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 5199 4305.500000 185784.0000 50.0000
P 721 745.000000 39849.5000 39865.2500
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
2503 2517.110000 127659.2900 89309.2100
Other 4 2.750000 101.7500 0.0000
---------------------------------------------------------
Total 8431 7572.610000 353477.7900 129224.4600
Center 55
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 30 25.500000 943.5000 0.0000
P 3240 3084.000000 128563.2500 128563.2500
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
3069 2904.500000 178240.7100 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 6339 6014.000000 307747.4600 128563.2500
Center 57
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 3 3.000000 111.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 2644 2529.500000 104101.2500 0.0000
P 945 976.250000 36234.2500 35890.0000
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
1293 4361.500000 222998.8300 222694.1700
Other 1 0.750000 27.7500 0.0000
---------------------------------------------------------
Total 4889 7872.500000 363502.5800 258484.1700