CMS/EIP Fiscal Report Statewide
Services beginning 04/01/2017 ending 06/30/2017 Date of Report:08/05/2017 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 16089 50202.75000 1856562.5000 36.9813
Subtotal (Total Children Is Unduplicated) 16089 50202.75000 1856562.5000 36.9813
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 121 199.500000 14962.5000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 77 129.000000 9675.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 26 39.500000 2962.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 94 149.000000 11175.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 165 268.500000 14901.7500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 1445 2140.000000 160475.0000 74.9883
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 697 1001.000000 75075.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 486 728.500000 54600.0000 74.9485
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 1952 2955.500000 163919.2500 55.4624
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 1041 1554.000000 116437.5000 74.9276
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 29 29.000000 1552.9500 53.5500
MED-99204-OUTPATIENT VISIT, NEW, 45 MINS 1 1.000000 75.7200 75.7200
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 2 2.000000 53.2200 26.6100
OCTF-97168-OT RE-EVAL EST PLAN CARE 6 6.000000 306.3000 51.0500
OCTH-97165-OT EVAL LOW COMPLEXITY 4 4.000000 204.2000 51.0500
OCTH-97166-OT EVAL MODERATE COMPLEXITY 7 7.000000 357.3500 51.0500
OCTH-97167-OT EVAL HIGH COMPLEXITY 28 32.000000 1633.6000 51.0500
PSTF-97164-PT RE-EVAL EST PLAN CARE 7 7.000000 357.3500 51.0500
PSTH-97162-PT EVAL MODERATE COMPLEXITY 2 2.000000 102.1000 51.0500
PSTH-97163-PT EVAL HIGH COMPLEXITY 33 34.000000 1735.7000 51.0500
SCREEN-T1023-SCREENING 79 79.000000 3950.0000 50.0000
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 32 32.000000 1633.6000 51.0500
SPCH-92524-BEHAV & QUAL ANALYSIS OF
VOICE AND RES 10 10.000000 510.5000 51.0500
Subtotal (Total Children Is Unduplicated) 3326 9409.500000 636656.0900 67.6610
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 1 1.000000 782.0400 782.0400
COUN-H2019HR-INDIVIDUAL/FAMILY THERAPY 5 10.000000 733.2000 73.3200
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 19 94.500000 2362.5000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 5878 44766.00000 2238077.0000 49.9950
OCCT-97530-OT SESSION BY LICENSED OT 307 1682.500000 120140.8400 71.4061
OCCT-97530HM-OT SESSION BY OT ASST 144 749.250000 42803.9000 57.1290
PHY-97110-PT SESSION BY LICENSED PT 299 1523.250000 108721.8000 71.3749
PHY-97110HM-PT SESSION BY PT ASST 71 403.250000 23049.7700 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 581 3452.000000 246570.1000 71.4282
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 1 8.000000 457.6000 57.2000
SPL-92508-GROUP SPL SESSION PER CHILD 6 20.750000 288.0100 13.8800
Subtotal (Total Children Is Unduplicated) 6675 52710.50000 2783986.7600 52.8166
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Total 112322.750000 5277205.3500 46.9825
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Number of Children (Unduplicated) With at Least One Service 17140
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Center 01
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 89 79.750000 3570.6700 0.0000
U 0 0.000000 0.0000 0.0000
B 8539 5851.750000 232075.5500 0.0000
P 17 17.000000 1860.7600 1860.7600
D 73 72.000000 4011.2400 0.0000
S 547 436.500000 16150.5000 0.0000
H 0 0.000000 0.0000 0.0000
T 14 13.250000 615.6900 421.4400
36 22.000000 871.0000 0.0000
Other 71 109.000000 7328.2500 0.0000
---------------------------------------------------------
Total 9386 6601.250000 266483.6600 2282.2000
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 1947 1462.750000 64022.0000 0.0000
---------------------------------------------------------
Total 1947 1462.750000 64022.0000 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 1606 998.500000 38228.2500 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
1320 823.500000 30646.9400 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 2926 1822.000000 68875.1900 0.0000
Center 04
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 1 2.750000 101.7500 0.0000
U 0 0.000000 0.0000 0.0000
B 3212 4946.750000 186561.0000 0.0000
P 1276 1681.750000 73756.3100 73773.8800
D 0 0.000000 0.0000 0.0000
S 2 1.750000 64.7500 0.0000
H 2729 11079.500000 560999.0700 387.8600
T 0 0.000000 0.0000 0.0000
456 609.000000 40059.3800 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 7676 18321.500000 861542.2600 74161.7400
Center 05
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 10 6.000000 222.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 2816 1909.500000 76661.0000 0.0000
P 1 1.000000 25.0000 25.0000
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
1 0.250000 9.2500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 2828 1916.750000 76917.2500 25.0000
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
5780 4350.250000 184431.5300 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 5780 4350.250000 184431.5300 0.0000
Center 07
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 24 20.250000 749.2500 0.0000
P 5833 4612.250000 190779.0000 190769.7500
D 0 0.000000 0.0000 0.0000
S 2 0.750000 27.7500 0.0000
H 0 0.000000 0.0000 0.0000
T 2 1.000000 37.0000 0.0000
94 101.500000 5098.5000 0.0000
Other 3 3.000000 111.0000 0.0000
---------------------------------------------------------
Total 5958 4738.750000 196802.5000 190769.7500
Center 09
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 2 3.000000 225.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 61 69.750000 3655.5000 0.0000
P 4538 4630.250000 190671.2500 193243.3190
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
2155 6826.000000 379612.8800 0.0000
Other 214 309.500000 22881.0000 0.0000
---------------------------------------------------------
Total 6970 11838.500000 597045.6300 193243.3190
Center 10
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 10 4.500000 166.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 10518 8246.000000 347868.0000 0.0000
P 1 0.250000 9.2500 0.0000
D 0 0.000000 0.0000 0.0000
S 3 3.500000 224.5000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
3308 11563.750000 592364.1700 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 13840 19818.000000 940632.4200 0.0000
Center 51
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 2478 1558.500000 61166.5000 0.0000
P 0 0.000000 0.0000 0.0000
D 32 15.000000 573.5000 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
862 2613.750000 153930.6600 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 3372 4187.250000 215670.6600 0.0000
Center 52
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 392 423.500000 21400.7500 142.5000
P 3126 2816.250000 129149.4800 128919.0000
D 8 6.000000 420.0300 0.0000
S 5 7.000000 450.0000 0.0000
H 148 129.750000 8956.1500 0.0000
T 0 0.000000 0.0000 0.0000
748 1522.250000 91464.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 4427 4904.750000 251840.4100 129061.5000
Center 53
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 3 1.500000 55.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 460 384.500000 16606.5000 1470.7500
P 4136 4012.250000 181204.2500 181148.7500
D 0 0.000000 0.0000 0.0000
S 3 2.500000 118.5000 18.5000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
2199 2235.000000 114478.9500 0.0000
Other 4 2.500000 93.5000 0.0000
---------------------------------------------------------
Total 6805 6638.250000 312557.2000 182638.0000
Center 54
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 3196 2672.250000 116383.7500 0.0000
P 30 29.000000 1505.5000 1487.0000
D 0 0.000000 0.0000 0.0000
S 2 2.250000 83.2500 0.0000
H 0 0.000000 0.0000 0.0000
T 15 11.000000 407.0000 388.5000
7231 6780.500000 325348.5800 0.0000
Other 3 0.750000 27.7500 0.0000
---------------------------------------------------------
Total 10477 9495.750000 443755.8300 1875.5000
Center 55
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 4 6.000000 374.0000 0.0000
P 4068 3682.750000 151195.2500 151084.4300
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
4029 3863.250000 238593.0700 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 8101 7552.000000 390162.3200 151084.4300
Center 57
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 2 3.000000 111.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 1329 1305.500000 50366.2500 0.0000
P 2127 2082.750000 88045.5000 88045.5000
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
1513 5236.000000 266176.9900 265426.7400
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 4971 8627.250000 404699.7400 353472.2400