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
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 14192 40345.25000 1491929.5000 36.9791
Subtotal (Total Children Is Unduplicated) 14192 40345.25000 1491929.5000 36.9791
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 74 120.762000 9057.1500 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 30 38.000000 2850.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 6 8.000000 600.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 39 63.000000 4725.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 87 134.000000 7437.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 863 1276.500000 95497.5200 74.8120
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 471 678.000000 50850.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 176 263.500000 19712.5000 74.8102
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 1191 1741.000000 96492.2500 55.4235
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 544 773.500000 57910.0200 74.8675
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
OCTH-97166-OT EVAL MODERATE COMPLEXITY 5 5.000000 255.2500 51.0500
PSTH-97161-PT EVAL LOW COMPLEXITY 1 1.000000 51.0500 51.0500
SCREEN-T1023-SCREENING 55 56.000000 2800.0000 50.0000
SPCH-92522-EVAL OF SPCH SOUND PROD 2 2.000000 102.1000 51.0500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 3 3.000000 153.1500 51.0500
Subtotal (Total Children Is Unduplicated) 2090 5171.262000 348894.4500 67.4680
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EI Services,Class #03
COUN-H2019HR-INDIVIDUAL/FAMILY THERAPY 11 21.000000 1539.7200 73.3200
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 4 7.000000 175.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 904 3892.250000 194612.5000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 30 117.500000 8394.2000 71.4400
OCCT-97530HM-OT SESSION BY OT ASST 1 1.000000 57.2000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 29 81.000000 5786.6400 71.4400
PHY-97110HM-PT SESSION BY PT ASST 3 26.000000 1486.1600 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 52 192.500000 13752.2000 71.4400
SPL-92508-GROUP SPL SESSION PER CHILD 1 1.000000 13.8800 13.8800
Subtotal (Total Children Is Unduplicated) 1000 4339.250000 225817.5000 52.0407
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Total 49855.762000 2066641.4500 41.4524
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Number of Children (Unduplicated) With at Least One Service 14414
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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 1 1.500000 112.5000 112.5000
D 0 0.000000 0.0000 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 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 7795 5286.500000 208317.6400 112.5000
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 1631 1205.000000 53345.7500 0.0000
---------------------------------------------------------
Total 1631 1205.000000 53345.7500 0.0000
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
283 200.000000 7452.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 2922 1753.750000 66345.2500 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 212 311.500000 11771.5000 0.0000
P 2998 4640.750000 179703.7500 179472.5000
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
203 176.500000 11264.4600 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 3426 5140.250000 203165.2100 179472.5000
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 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 1 0.500000 18.5000 0.0000
1 0.250000 9.2500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 2956 1804.250000 70923.5000 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
4374 3245.500000 136449.5000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 4374 3245.500000 136449.5000 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
65 41.000000 1559.2500 0.0000
Other 1 1.250000 46.2500 0.0000
---------------------------------------------------------
Total 4732 3433.750000 137032.2500 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
0 0.000000 0.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 3981 4004.250000 165343.3000 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
14 19.250000 712.2500 0.0000
Other 4 1.250000 46.2500 0.0000
---------------------------------------------------------
Total 9129 6875.250000 288595.7500 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 0 0.000000 0.0000 0.0000
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
15 7.000000 259.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 1842 1087.000000 42175.7500 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 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
79 74.250000 5004.8600 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 3004 2638.250000 127131.7100 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
574 447.250000 21594.9300 0.0000
Other 4 5.500000 306.8200 0.0000
---------------------------------------------------------
Total 3548 3184.000000 143930.6900 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
363 319.250000 13060.1000 0.0000
Other 2 3.000000 168.0000 0.0000
---------------------------------------------------------
Total 5246 4217.250000 182274.6800 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
1 0.762000 57.1500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 3693 3209.762000 129355.9000 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
10 13.500000 790.8200 214.3200
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 2887 2771.000000 112254.5700 40336.0700