CMS/EIP Fiscal Report Statewide
Services beginning 10/01/2017 ending 12/31/2017 Date of Report:02/03/2018 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 14087 40710.25000 1504958.9900 36.9676
Subtotal (Total Children Is Unduplicated) 14087 40710.25000 1504958.9900 36.9676
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 89 139.000000 10425.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 66 94.000000 7050.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 23 32.500000 2437.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 52 84.000000 6280.5000 74.7679
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 125 189.000000 10489.5000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 1158 1782.500000 133602.5000 74.9523
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 568 866.500000 64987.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 349 546.000000 40950.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 1470 2193.000000 121637.2500 55.4661
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 661 996.000000 74700.0000 75.0000
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 36 36.000000 1927.8000 53.5500
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 8 8.000000 212.8800 26.6100
MED-99214-OUTPATIENT VISIT, EST, 25 MINS 1 1.000000 41.4600 41.4600
OCTF-97168-OT RE-EVAL EST PLAN CARE 10 10.000000 510.5000 51.0500
OCTH-97165-OT EVAL LOW COMPLEXITY 2 2.000000 102.1000 51.0500
OCTH-97166-OT EVAL MODERATE COMPLEXITY 5 5.000000 255.2500 51.0500
OCTH-97167-OT EVAL HIGH COMPLEXITY 33 33.000000 1684.6500 51.0500
PSTF-97164-PT RE-EVAL EST PLAN CARE 8 8.000000 408.4000 51.0500
PSTH-97162-PT EVAL MODERATE COMPLEXITY 3 3.000000 153.1500 51.0500
PSTH-97163-PT EVAL HIGH COMPLEXITY 42 42.000000 2144.1000 51.0500
SCREEN-T1023-SCREENING 47 47.000000 2350.0000 50.0000
SPCH-92521-EVAL OF SPEECH FLUENCY 1 1.000000 51.0500 51.0500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 54 54.000000 2755.6500 51.0306
SPCH-92524-BEHAV & QUAL ANALYSIS OF
VOICE AND RES 4 4.000000 204.2000 51.0500
Subtotal (Total Children Is Unduplicated) 2541 7176.500000 485360.9400 67.6320
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EI Services,Class #03
COUN-H2019HR-INDIVIDUAL/FAMILY THERAPY 3 6.000000 439.9200 73.3200
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 11 28.000000 700.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 5457 42337.25000 2116395.0000 49.9890
OCCT-97530-OT SESSION BY LICENSED OT 287 1675.568300 119624.6600 71.3935
OCCT-97530HM-OT SESSION BY OT ASST 122 682.000000 39010.4000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 285 1574.500000 112266.5200 71.3030
PHY-97110HM-PT SESSION BY PT ASST 88 619.750000 35424.9100 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 557 3307.000000 236004.5200 71.3651
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 2 7.000000 400.4000 57.2000
SPL-92508-GROUP SPL SESSION PER CHILD 15 41.500000 576.0200 13.8800
Subtotal (Total Children Is Unduplicated) 6223 50278.56830 2660842.3500 52.9220
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Total 98165.318300 4651162.2800 47.3809
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Number of Children (Unduplicated) With at Least One Service 15293
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Center 01
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 3 0.750000 27.7500 0.0000
U 0 0.000000 0.0000 0.0000
B 7275 4870.250000 192545.4600 0.0000
P 102 104.500000 5357.8000 5357.8000
D 179 181.750000 11897.5500 0.0000
S 162 138.750000 7062.4300 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
82 100.500000 6569.3600 0.0000
Other 193 235.500000 14120.9700 0.0000
---------------------------------------------------------
Total 7996 5632.000000 237581.3200 5357.8000
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 1505 1147.750000 51022.0000 0.0000
---------------------------------------------------------
Total 1505 1147.750000 51022.0000 0.0000
Center 03
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 22 27.750000 1377.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 2770 1725.250000 69056.2500 0.0000
P 0 0.000000 0.0000 0.0000
D 0 0.000000 0.0000 0.0000
S 1 1.750000 64.7500 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 2793 1754.750000 70498.5000 0.0000
Center 04
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 40 45.750000 1692.7500 0.0000
U 0 0.000000 0.0000 0.0000
B 579 888.000000 34253.0000 0.0000
P 2661 4139.000000 161421.5900 161534.5900
D 0 0.000000 0.0000 0.0000
S 1 3.000000 111.0000 0.0000
H 2546 10404.500000 529409.0700 0.0000
T 0 0.000000 0.0000 0.0000
455 714.500000 46894.0700 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 6282 16194.750000 773781.4800 161534.5900
Center 05
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 2573 1603.250000 64004.5000 0.0000
P 3 3.000000 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 0 0.000000 0.0000 0.0000
2 0.750000 27.7500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 2578 1607.000000 64182.2500 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
4481 3298.750000 137272.4400 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 4481 3298.750000 137272.4400 0.0000
Center 07
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 19 12.500000 538.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 8 7.250000 496.2500 0.0000
P 4687 3652.500000 149323.0000 149323.0000
D 0 0.000000 0.0000 0.0000
S 5 9.500000 364.5000 0.0000
H 0 0.000000 0.0000 0.0000
T 1 0.500000 18.5000 0.0000
16 7.500000 303.5000 0.0000
Other 2 0.500000 18.5000 0.0000
---------------------------------------------------------
Total 4738 3690.250000 151062.7500 149323.0000
Center 09
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 56 61.750000 3084.7500 0.0000
P 4095 4180.250000 172755.7500 172784.0070
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
2037 6435.500000 355949.2700 0.0000
Other 140 223.000000 16315.5000 0.0000
---------------------------------------------------------
Total 6328 10900.500000 548105.2700 172784.0070
Center 10
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 31 15.000000 555.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 8880 7014.750000 295890.0000 0.0000
P 0 0.000000 0.0000 0.0000
D 0 0.000000 0.0000 0.0000
S 10 17.750000 1204.7500 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
3300 11797.500000 603474.4100 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 12221 18845.000000 901124.1600 0.0000
Center 51
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 3 2.000000 74.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 1338 866.250000 33763.5000 0.0000
P 3 8.000000 464.3200 364.3200
D 9 5.500000 203.5000 0.0000
S 1 0.500000 18.5000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
702 1992.000000 117619.8200 0.0000
Other 1 0.500000 18.5000 0.0000
---------------------------------------------------------
Total 2057 2874.750000 152162.1400 364.3200
Center 52
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 66 73.750000 3978.2500 37.0000
P 2837 2568.500000 121432.7500 120124.5500
D 59 50.000000 2687.6100 0.0000
S 30 25.500000 1165.5000 0.0000
H 53 50.000000 3416.9800 0.0000
T 1 4.000000 200.0000 0.0000
780 1551.000000 90939.0300 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 3826 4322.750000 223820.1200 120161.5500
Center 53
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 947 870.500000 38154.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 214 153.250000 6103.0000 0.0000
P 1548 1543.000000 69463.7500 69463.7500
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
2718 2800.250000 140243.8100 0.0000
Other 2 2.000000 74.0000 0.0000
---------------------------------------------------------
Total 5429 5369.000000 254039.0600 69463.7500
Center 54
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 1385 1119.750000 47042.2500 0.0000
U 0 0.000000 0.0000 0.0000
B 3048 2463.750000 108226.8500 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
5011 4908.250000 240753.2400 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 9444 8491.750000 396022.3400 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 0.750000 27.7500 0.0000
P 3499 2960.500000 118787.7500 118787.7500
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
3793 3529.000000 217039.7500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 7294 6490.250000 335855.2500 118787.7500
Center 57
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 2431 2486.750000 99109.7500 0.0000
P 244 213.750000 9903.8900 9903.9400
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 2 6.000000 300.0000 300.0000
1363 4839.568300 245319.5600 244918.3100
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 4040 7546.068300 354633.2000 255122.2500