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:Program Patients
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 15235 44251.75000 1636388.7500 36.9791
Subtotal (Total Children Is Unduplicated) 15235 44251.75000 1636388.7500 36.9791
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 95 153.262000 11494.6500 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 41 58.500000 4387.5000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 19 30.500000 2287.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 49 77.000000 5775.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 137 223.000000 12376.5000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 1254 1853.000000 138735.0200 74.8705
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 632 912.500000 68387.5000 74.9452
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 407 649.500000 48662.5000 74.9230
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 1757 2608.000000 144560.7500 55.4297
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 817 1169.000000 87572.5200 74.9123
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 8 8.000000 428.4000 53.5500
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 1 1.000000 26.6100 26.6100
OCTF-97168-OT RE-EVAL EST PLAN CARE 6 6.000000 306.3000 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 59 60.000000 3000.0000 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) 2916 7966.262000 536015.6000 67.2857
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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 5537 38036.25000 1901674.5000 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) 6326 45384.50000 2403711.2700 52.9633
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Total 97602.512000 4576115.6200 46.8852
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Number of Children (Unduplicated) With at Least One Service 16510
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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 7082 4764.750000 189434.0100 0.0000
P 3 3.500000 255.3800 255.3800
D 92 94.000000 5033.6400 0.0000
S 1107 841.500000 31777.9400 0.0000
H 0 0.000000 0.0000 0.0000
T 1 0.500000 18.5000 0.0000
24 19.250000 822.6900 0.0000
Other 117 121.500000 7285.0600 0.0000
---------------------------------------------------------
Total 8431 5848.500000 234795.7200 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 1820 1357.750000 59891.2500 0.0000
---------------------------------------------------------
Total 1822 1359.750000 59991.2500 100.0000
Center 03
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 61 56.750000 2112.7500 0.0000
U 0 0.000000 0.0000 0.0000
B 2813 1683.500000 63681.0000 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
331 247.000000 9278.4900 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 3205 1987.250000 75072.2400 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 293 381.500000 14380.5000 0.0000
P 3357 5212.500000 202532.5000 202301.2500
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
476 567.250000 37486.7300 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 6519 15547.250000 730946.7500 202758.5300
Center 05
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 3105 1937.250000 76509.5000 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 3109 1942.000000 76687.2500 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
4613 3526.500000 151023.5000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 4613 3526.500000 151023.5000 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 22 18.250000 751.2500 0.0000
P 5000 3792.500000 154450.0000 154450.0000
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
74 62.250000 2566.5000 0.0000
Other 2 1.500000 55.5000 0.0000
---------------------------------------------------------
Total 5109 3885.500000 158363.2500 154450.0000
Center 09
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 10 7.500000 334.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 201 175.500000 7200.5700 683.2500
P 4033 4256.750000 178494.2300 178420.2300
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
2121 6314.500000 350541.0200 0.0000
Other 175 279.500000 20748.0000 0.0000
---------------------------------------------------------
Total 6540 11033.750000 557318.3200 179103.4800
Center 10
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 13 10.000000 370.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 9425 7171.750000 300508.5000 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 12088 16348.000000 769619.3300 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 1872 1136.750000 44295.0000 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
832 2519.000000 145630.1800 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 2769 3690.000000 191274.3100 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 814 803.500000 43598.2500 9.2500
P 2194 1887.250000 82528.2100 82153.4000
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
693 1484.750000 88577.7000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 3833 4290.500000 222516.8000 82162.6500
Center 53
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 9 7.500000 342.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 407 295.500000 10933.5000 0.0000
P 2862 2767.250000 126091.9400 126091.9400
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
2351 2298.750000 116706.1000 0.0000
Other 4 5.500000 306.8200 0.0000
---------------------------------------------------------
Total 5633 5374.500000 254380.8600 126091.9400
Center 54
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 1 0.250000 9.2500 0.0000
U 0 0.000000 0.0000 0.0000
B 5572 4556.500000 199031.0800 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
3112 3141.750000 157512.1200 0.0000
Other 2 3.000000 168.0000 0.0000
---------------------------------------------------------
Total 8690 7703.750000 356816.7000 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 4130 3750.250000 153353.0000 153353.0000
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
3726 3583.512000 221581.0900 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 7858 7335.012000 374980.3400 153353.0000
Center 57
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 56 41.250000 1563.7500 0.0000
U 0 0.000000 0.0000 0.0000
B 1901 1835.000000 73327.0000 0.0000
P 1039 1027.000000 42784.0000 42747.0000
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
1363 4827.000000 244654.2500 244020.5900
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 4359 7730.250000 362329.0000 286767.5900