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
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 13992 40525.75000 1498132.4900 36.9674
Subtotal (Total Children Is Unduplicated) 13992 40525.75000 1498132.4900 36.9674
-----------------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 86 134.000000 10050.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 56 75.000000 5625.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 18 25.000000 1875.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 45 71.500000 5343.0000 74.7273
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 82 112.000000 6216.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 1033 1588.500000 119052.5000 74.9465
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 513 769.500000 57712.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 231 344.500000 25837.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 1211 1763.000000 97772.2500 55.4579
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 535 805.500000 60412.5000 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
OCTH-97165-OT EVAL LOW COMPLEXITY 2 2.000000 102.1000 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 6 6.000000 306.3000 51.0500
Subtotal (Total Children Is Unduplicated) 2286 5789.500000 394887.8400 68.2076
-----------------------------------------------------------------------------------------------------------------------
EI Services,Class #03
COUN-H2019HR-INDIVIDUAL/FAMILY THERAPY 1 4.000000 293.2800 73.3200
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 6 10.000000 250.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 820 4042.500000 201975.0000 49.9629
OCCT-97530-OT SESSION BY LICENSED OT 27 118.000000 8429.9200 71.4400
OCCT-97530HM-OT SESSION BY OT ASST 1 3.000000 171.6000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 33 107.500000 7679.8000 71.4400
PHY-97110HM-PT SESSION BY PT ASST 3 23.000000 1314.6800 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 70 289.750000 20699.7400 71.4400
SPL-92508-GROUP SPL SESSION PER CHILD 3 12.000000 166.5600 13.8800
Subtotal (Total Children Is Unduplicated) 931 4609.750000 240980.5800 52.2763
-----------------------------------------------------------------------------------------------------------------------
Total 50925.000000 2134000.9100 41.9048
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 14210
-----------------------------------------------------------------------------------------------------------------------
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 56 56.000000 3943.0800 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 1 1.500000 112.5000 0.0000
---------------------------------------------------------
Total 7681 5272.250000 215618.3800 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 39 45.500000 1683.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 492 813.000000 31478.0000 0.0000
P 2577 4078.250000 159173.8400 159286.8400
D 0 0.000000 0.0000 0.0000
S 1 3.000000 111.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
228 208.500000 12966.3000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 3337 5148.250000 205412.6400 159286.8400
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
4454 3246.750000 133873.2500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 4454 3246.750000 133873.2500 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 4093 4177.750000 172568.2500 172596.5070
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 4149 4239.500000 175653.0000 172596.5070
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
4 4.500000 205.5000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 8925 7052.000000 297855.2500 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 0 0.000000 0.0000 0.0000
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
14 15.250000 667.5700 0.0000
Other 1 0.500000 18.5000 0.0000
---------------------------------------------------------
Total 1366 890.000000 34745.5700 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 66 73.750000 3978.2500 37.0000
P 2836 2566.500000 121282.7500 119974.5500
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 0 0.000000 0.0000 0.0000
171 142.750000 8063.2000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 3215 2908.500000 140594.2900 120011.5500
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
755 756.750000 35092.6800 0.0000
Other 2 2.000000 74.0000 0.0000
---------------------------------------------------------
Total 3466 3325.500000 148887.9300 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
1560 1387.500000 60901.0400 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 5993 4971.000000 216170.1400 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
3 1.500000 69.5500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 3504 2962.750000 118885.0500 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 242 207.750000 9475.2500 9475.3000
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 14.250000 954.9100 553.6600
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 2683 2708.750000 109539.9100 10028.9600