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:Program Patients
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 14974 44227.50000 1634941.9900 36.9666
Subtotal (Total Children Is Unduplicated) 14974 44227.50000 1634941.9900 36.9666
-----------------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 111 172.500000 12937.5000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 71 103.000000 7725.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 26 37.000000 2775.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 65 107.000000 8005.5000 74.8178
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 154 234.000000 12987.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 1466 2239.000000 167840.0000 74.9620
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 724 1092.000000 81900.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 437 677.000000 50775.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 1877 2778.500000 154120.2500 55.4689
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 861 1275.500000 95662.5000 75.0000
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 46 46.000000 2463.3000 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) 3178 8979.500000 608064.4400 67.7170
-----------------------------------------------------------------------------------------------------------------------
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 5461 42362.25000 2117645.0000 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 90 632.750000 36167.9900 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) 6229 50316.56830 2662835.4300 52.9216
-----------------------------------------------------------------------------------------------------------------------
Total 103523.568300 4905841.8600 47.3886
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 16208
-----------------------------------------------------------------------------------------------------------------------
Center 01
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 4 2.750000 177.7500 0.0000
U 0 0.000000 0.0000 0.0000
B 7546 5116.000000 202441.9600 0.0000
P 104 107.000000 5516.0500 5516.0500
D 179 181.750000 11897.5500 0.0000
S 168 142.750000 7324.4300 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
94 113.750000 7485.8600 0.0000
Other 201 247.000000 14846.9700 0.0000
---------------------------------------------------------
Total 8296 5911.000000 249690.5700 5516.0500
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 1606 1239.500000 55114.7500 0.0000
---------------------------------------------------------
Total 1606 1239.500000 55114.7500 0.0000
Center 03
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 26 30.750000 1488.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 3053 2000.250000 81356.2500 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 3080 2032.750000 82909.5000 0.0000
Center 04
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 44 61.250000 2266.2500 0.0000
U 0 0.000000 0.0000 0.0000
B 621 960.750000 37359.2500 0.0000
P 2941 4661.750000 182921.9900 183076.8700
D 0 0.000000 0.0000 0.0000
S 2 5.000000 185.0000 0.0000
H 2549 10417.500000 530059.0700 0.0000
T 0 0.000000 0.0000 0.0000
516 763.500000 49999.6700 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 6673 16869.750000 802791.2300 183076.8700
Center 05
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 2792 1787.750000 72294.0000 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
3 1.000000 37.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 2798 1791.750000 72481.0000 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
4611 3429.750000 143584.6900 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 4611 3429.750000 143584.6900 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 11 8.000000 524.0000 0.0000
P 5072 4090.000000 169860.7500 169860.7500
D 0 0.000000 0.0000 0.0000
S 6 9.750000 373.7500 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 5127 4128.750000 171637.5000 169860.7500
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 4284 4501.250000 188004.2500 188032.5070
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
2042 6444.000000 356586.7700 0.0000
Other 184 287.000000 21037.5000 0.0000
---------------------------------------------------------
Total 6566 11294.000000 568713.2700 188032.5070
Center 10
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 32 17.750000 656.7500 0.0000
U 0 0.000000 0.0000 0.0000
B 9267 7488.000000 318596.2500 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
3301 11798.750000 603520.6600 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 12610 19322.250000 923978.4100 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 1377 901.500000 35234.2500 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
713 2003.000000 118444.8200 0.0000
Other 1 0.500000 18.5000 0.0000
---------------------------------------------------------
Total 2107 2921.000000 154457.8900 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 75 88.250000 4875.7500 37.0000
P 3045 2828.000000 133618.5000 132310.3000
D 63 56.750000 3070.3600 0.0000
S 38 33.250000 1452.2500 0.0000
H 53 50.000000 3416.9800 0.0000
T 1 4.000000 200.0000 0.0000
799 1579.000000 92830.0300 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 4074 4639.250000 239463.8700 132347.3000
Center 53
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 1048 972.750000 42853.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 238 175.250000 7001.7500 0.0000
P 1670 1697.750000 77286.0000 77286.0000
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
2870 2984.500000 149726.3100 0.0000
Other 3 2.250000 83.2500 0.0000
---------------------------------------------------------
Total 5829 5832.500000 276950.8100 77286.0000
Center 54
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 1535 1276.500000 53894.2500 0.0000
U 0 0.000000 0.0000 0.0000
B 3381 2781.000000 123434.3500 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
5320 5278.000000 259273.4900 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 10236 9335.500000 436602.0900 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 3 1.250000 46.2500 0.0000
P 3894 3459.250000 140965.5000 140965.5000
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
3885 3670.500000 226915.3300 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 7782 7131.000000 367927.0800 140965.5000
Center 57
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 2494 2567.000000 102851.0000 0.0000
P 249 220.250000 10285.6400 10285.6900
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
1369 4851.568300 246102.5600 245701.3100
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 4114 7644.818300 359539.2000 256287.0000