CMS/EIP Fiscal Report Statewide
Services beginning 07/01/2017 ending 09/30/2017 Date of Report:11/05/2017 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 14266 40498.50000 1497599.7500 36.9791
Subtotal (Total Children Is Unduplicated) 14266 40498.50000 1497599.7500 36.9791
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 79 127.762000 9582.1500 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 38 54.000000 4050.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 12 19.500000 1462.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 42 67.000000 5025.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 122 201.000000 11155.5000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 977 1450.500000 108547.5200 74.8346
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 524 772.500000 57937.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 320 517.500000 38762.5000 74.9034
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 1369 2046.500000 113447.5000 55.4349
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 643 920.000000 68897.5200 74.8886
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 7 7.000000 374.8500 53.5500
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 1 1.000000 26.6100 26.6100
OCTF-97168-OT RE-EVAL EST PLAN CARE 5 5.000000 255.2500 51.0500
OCTH-97165-OT EVAL LOW COMPLEXITY 3 3.000000 153.1500 51.0500
OCTH-97166-OT EVAL MODERATE COMPLEXITY 12 12.000000 612.6000 51.0500
OCTH-97167-OT EVAL HIGH COMPLEXITY 44 44.000000 2246.2000 51.0500
PSTF-97164-PT RE-EVAL EST PLAN CARE 5 5.000000 255.2500 51.0500
PSTH-97161-PT EVAL LOW COMPLEXITY 1 1.000000 51.0500 51.0500
PSTH-97162-PT EVAL MODERATE COMPLEXITY 1 1.000000 51.0500 51.0500
PSTH-97163-PT EVAL HIGH COMPLEXITY 46 46.000000 2348.3000 51.0500
SCREEN-T1023-SCREENING 55 56.000000 2800.0000 50.0000
SPCH-92522-EVAL OF SPCH SOUND PROD 3 3.000000 153.1500 51.0500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 37 37.000000 1888.8500 51.0500
SPCH-92524-BEHAV & QUAL ANALYSIS OF
VOICE AND RES 5 5.000000 255.2500 51.0500
Subtotal (Total Children Is Unduplicated) 2323 6402.262000 430339.2500 67.2168
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EI Services,Class #03
COUN-H2019HR-INDIVIDUAL/FAMILY THERAPY 12 25.000000 1833.0000 73.3200
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 13 65.000000 1625.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 5533 38006.25000 1900174.5000 49.9964
OCCT-97530-OT SESSION BY LICENSED OT 318 1575.250000 112485.9000 71.4083
OCCT-97530HM-OT SESSION BY OT ASST 120 703.250000 40225.9000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 268 1205.500000 85980.1200 71.3232
PHY-97110HM-PT SESSION BY PT ASST 107 524.250000 29966.1300 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 554 3195.500000 228189.5600 71.4097
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 6 22.500000 1287.0000 57.2000
SPL-92508-GROUP SPL SESSION PER CHILD 8 32.000000 444.1600 13.8800
Subtotal (Total Children Is Unduplicated) 6322 45354.50000 2402211.2700 52.9652
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Total 92255.262000 4330150.2700 46.9366
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Number of Children (Unduplicated) With at Least One Service 15524
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Center 01
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 5 3.500000 168.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 6718 4475.500000 177575.7600 0.0000
P 3 3.500000 255.3800 255.3800
D 92 94.000000 5033.6400 0.0000
S 1047 787.250000 29656.6900 0.0000
H 0 0.000000 0.0000 0.0000
T 1 0.500000 18.5000 0.0000
23 18.250000 785.6900 0.0000
Other 115 117.500000 7024.0600 0.0000
---------------------------------------------------------
Total 8004 5500.000000 220518.2200 255.3800
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 2 2.000000 100.0000 100.0000
0 0.000000 0.0000 0.0000
Other 1631 1205.000000 53345.7500 0.0000
---------------------------------------------------------
Total 1633 1207.000000 53445.7500 100.0000
Center 03
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 53 45.750000 1705.7500 0.0000
U 0 0.000000 0.0000 0.0000
B 2586 1508.000000 57187.5000 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
288 205.000000 7724.4900 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 2927 1758.750000 66617.7400 0.0000
Center 04
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 12 11.250000 416.2500 0.0000
U 0 0.000000 0.0000 0.0000
B 275 347.250000 13094.2500 0.0000
P 3112 4757.500000 184023.5000 183792.2500
D 0 0.000000 0.0000 0.0000
S 1 0.250000 9.2500 0.0000
H 2380 9374.500000 476121.5200 457.2800
T 0 0.000000 0.0000 0.0000
420 521.750000 34583.1800 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 6200 15012.500000 708247.9500 184249.5300
Center 05
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 2954 1803.500000 70895.7500 0.0000
P 2 4.000000 150.0000 150.0000
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 1 0.500000 18.5000 0.0000
1 0.250000 9.2500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 2958 1808.250000 71073.5000 150.0000
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
4420 3326.500000 141568.5000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 4420 3326.500000 141568.5000 0.0000
Center 07
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 7 6.500000 240.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 18 14.750000 621.7500 0.0000
P 4637 3365.750000 134265.0000 134265.0000
D 0 0.000000 0.0000 0.0000
S 3 4.000000 281.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 1 0.500000 18.5000 0.0000
71 58.000000 2409.2500 0.0000
Other 1 1.250000 46.2500 0.0000
---------------------------------------------------------
Total 4738 3450.750000 137882.2500 134265.0000
Center 09
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 9 6.000000 222.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 193 163.750000 6548.0700 375.0000
P 3779 3834.500000 158573.2300 158499.2300
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
2107 6293.500000 348966.0200 0.0000
Other 131 212.500000 15723.0000 0.0000
---------------------------------------------------------
Total 6219 10510.250000 530032.3200 158874.2300
Center 10
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 6 6.000000 222.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 9061 6778.500000 282622.0000 0.0000
P 0 0.000000 0.0000 0.0000
D 0 0.000000 0.0000 0.0000
S 44 70.250000 4993.2500 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
2602 9094.750000 463701.3300 0.0000
Other 4 1.250000 46.2500 0.0000
---------------------------------------------------------
Total 11717 15950.750000 751584.8300 0.0000
Center 51
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 45 22.250000 823.2500 0.0000
U 0 0.000000 0.0000 0.0000
B 1763 1047.750000 40710.5000 0.0000
P 1 2.000000 142.8800 142.8800
D 18 9.000000 333.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 1 1.000000 50.0000 0.0000
T 0 0.000000 0.0000 0.0000
813 2500.000000 144205.1800 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 2641 3582.000000 186264.8100 142.8800
Center 52
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 752 727.750000 39102.7500 9.2500
P 2041 1721.250000 75211.4600 74836.6500
D 19 14.750000 1010.8600 0.0000
S 2 2.000000 100.0000 0.0000
H 111 98.250000 6701.7800 0.0000
T 0 0.000000 0.0000 0.0000
688 1475.750000 87902.7000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 3613 4039.750000 210029.5500 74845.9000
Center 53
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 9 7.500000 342.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 348 244.500000 9046.5000 0.0000
P 2613 2479.250000 112639.9400 112639.9400
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
2275 2216.500000 112204.6000 0.0000
Other 4 5.500000 306.8200 0.0000
---------------------------------------------------------
Total 5249 4953.250000 234540.3600 112639.9400
Center 54
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 1 0.250000 9.2500 0.0000
U 0 0.000000 0.0000 0.0000
B 4877 3892.500000 168941.0800 0.0000
P 1 1.000000 50.0000 0.0000
D 0 0.000000 0.0000 0.0000
S 2 1.250000 46.2500 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
2993 2994.500000 150092.6200 0.0000
Other 2 3.000000 168.0000 0.0000
---------------------------------------------------------
Total 7876 6892.500000 319307.2000 0.0000
Center 55
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 2 1.250000 46.2500 0.0000
P 3690 3207.750000 129252.5000 129252.5000
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
3672 3481.512000 214403.5400 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 7364 6690.512000 343702.2900 129252.5000
Center 57
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 55 40.250000 1526.7500 0.0000
U 0 0.000000 0.0000 0.0000
B 1834 1748.750000 69778.2500 0.0000
P 988 968.500000 40158.7500 40121.7500
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
1357 4815.000000 243871.2500 243237.5900
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 4234 7572.500000 355335.0000 283359.3400