CMS/EIP Fiscal Report Statewide
Services beginning 10/01/2018 ending 12/31/2018 Date of Report:02/06/2019 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 14093 38776.75000 1433306.5000 36.9630
Subtotal (Total Children Is Unduplicated) 14093 38776.75000 1433306.5000 36.9630
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 98 155.500000 11662.5000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 43 59.500000 4462.5000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 12 19.000000 1425.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 49 73.000000 5475.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 85 125.500000 6965.2500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 1076 1714.000000 128550.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 494 732.500000 54937.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 167 276.000000 20700.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 1339 2082.000000 115551.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 667 1074.000000 80512.5000 74.9651
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 19 19.000000 1119.2900 58.9100
MED-99204-OUTPATIENT VISIT, NEW, 45 MINS 6 6.000000 499.7400 83.2900
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 9 9.000000 210.7800 23.4200
MED-99214-OUTPATIENT VISIT, EST, 25 MINS 1 1.000000 36.4900 36.4900
SCREEN-T1023-SCREENING 47 48.000000 2400.0000 50.0000
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 3 3.000000 153.1500 51.0500
Subtotal (Total Children Is Unduplicated) 2454 6397.000000 434660.7000 67.9476
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EI Services,Class #03
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 15 22.000000 550.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 906 4452.750000 222612.5000 49.9944
OCCT-97530-OT SESSION BY LICENSED OT 10 53.000000 3786.3200 71.4400
PHY-97110-PT SESSION BY LICENSED PT 18 47.500000 3393.4000 71.4400
PHY-97110HM-PT SESSION BY PT ASST 3 4.000000 228.6400 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 54 227.500000 16209.7200 71.2515
Subtotal (Total Children Is Unduplicated) 981 4806.750000 246780.5800 51.3404
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Total 49980.500000 2114747.7800 42.3115
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Number of Children (Unduplicated) With at Least One Service 14374
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Center 01
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 600 432.250000 17890.0900 0.0000
U 0 0.000000 0.0000 0.0000
B 700 769.750000 46448.6200 0.0000
P 6002 3806.000000 140666.2500 140456.7000
D 13 8.000000 296.0000 0.0000
S 2 2.000000 74.0000 0.0000
H 2 1.000000 37.0000 37.0000
T 1 0.750000 27.7500 0.0000
8 2.250000 83.2500 0.0000
Other 5 7.500000 543.0000 0.0000
---------------------------------------------------------
Total 7333 5029.500000 206065.9600 140493.7000
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 1526 1117.500000 50100.2500 0.0000
---------------------------------------------------------
Total 1526 1117.500000 50100.2500 0.0000
Center 03
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 92 67.500000 3069.2500 0.0000
U 0 0.000000 0.0000 0.0000
B 2657 1902.250000 82527.0000 0.0000
P 0 0.000000 0.0000 0.0000
D 0 0.000000 0.0000 0.0000
S 2 1.750000 64.7500 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
22 37.000000 2564.7500 0.0000
Other 1 0.500000 18.5000 0.0000
---------------------------------------------------------
Total 2774 2009.000000 88244.2500 0.0000
Center 04
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 8 8.500000 314.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 1102 1621.250000 62689.0000 0.0000
P 2446 3897.750000 153367.6500 153478.8900
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
286 260.500000 14830.4000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 3842 5788.000000 231201.5500 153478.8900
Center 05
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 65 46.250000 1711.2500 0.0000
U 0 0.000000 0.0000 0.0000
B 2137 1412.750000 55546.5000 0.0000
P 2 2.500000 187.5000 187.5000
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 0.750000 27.7500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 2205 1462.250000 57473.0000 187.5000
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
5296 3881.750000 164335.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 5296 3881.750000 164335.0000 0.0000
Center 07
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 13 9.500000 351.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 40 36.000000 1421.0000 0.0000
P 3564 3055.750000 129006.7500 128942.0000
D 0 0.000000 0.0000 0.0000
S 8 8.000000 400.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
31 21.250000 880.7500 0.0000
Other 2 1.000000 37.0000 0.0000
---------------------------------------------------------
Total 3658 3131.500000 132097.0000 128942.0000
Center 09
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 189 222.750000 8241.7500 0.0000
U 0 0.000000 0.0000 0.0000
B 1700 1599.250000 62514.0000 124.5000
P 2889 2918.500000 120148.2500 120038.3300
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 1 1.000000 37.0000 0.0000
---------------------------------------------------------
Total 4779 4741.500000 190941.0000 120162.8300
Center 10
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 384 297.750000 11016.7500 0.0000
U 0 0.000000 0.0000 0.0000
B 5036 4589.250000 201863.2500 0.0000
P 0 0.000000 0.0000 0.0000
D 0 0.000000 0.0000 0.0000
S 64 99.750000 6179.7500 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
5 9.000000 419.1000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 5489 4995.750000 219478.8500 0.0000
Center 51
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 225 163.250000 5938.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 571 392.500000 15111.0000 0.0000
P 0 0.000000 0.0000 0.0000
D 1 0.750000 27.7500 0.0000
S 0 0.000000 0.0000 0.0000
H 1 0.250000 9.2500 0.0000
T 0 0.000000 0.0000 0.0000
13 8.500000 314.5000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 811 565.250000 21401.0000 0.0000
Center 52
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 7 3.500000 142.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 1012 990.250000 48275.2500 83.2500
P 2259 2085.500000 94863.5500 93920.2100
D 4 4.000000 221.4400 0.0000
S 6 7.000000 259.0000 0.0000
H 46 43.750000 2955.0300 0.0000
T 1 1.000000 50.0000 50.0000
51 45.000000 2950.4500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 3386 3180.000000 149717.2200 94053.4600
Center 53
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 21 18.500000 739.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 773 715.500000 29755.7500 2.0000
P 2656 2680.500000 125552.7500 125515.7500
D 0 0.000000 0.0000 0.0000
S 17 17.750000 720.5000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
209 190.250000 8282.0000 0.0000
Other 2 2.000000 100.0000 0.0000
---------------------------------------------------------
Total 3678 3624.500000 165150.5000 125517.7500
Center 54
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 3 3.000000 150.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 1618 1251.500000 49967.0000 0.0000
P 3677 3184.000000 141169.5000 159531.0000
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
426 377.250000 16561.2000 0.0000
Other 3 1.750000 64.7500 0.0000
---------------------------------------------------------
Total 5727 4817.500000 207912.4500 159531.0000
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 0.500000 18.5000 0.0000
P 3275 2663.500000 111179.5000 111179.5000
D 0 0.000000 0.0000 0.0000
S 5 3.500000 168.5000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
3 2.000000 74.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 3285 2669.500000 111440.5000 111179.5000
Center 57
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 1 0.500000 18.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 2167 2631.500000 98693.2500 0.0000
P 318 333.250000 20399.7500 20210.5500
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 1.750000 77.7500 50.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 2488 2967.000000 119189.2500 20260.5500