CMS/EIP Fiscal Report Statewide
Services beginning 07/01/2019 ending 09/30/2019 Date of Report:11/04/2019 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 15339 45432.25000 1679680.7500 36.9711
Subtotal (Total Children Is Unduplicated) 15339 45432.25000 1679680.7500 36.9711
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 88 139.000000 10425.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 28 41.000000 3075.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 17 26.500000 1987.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 68 119.500000 8962.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 97 137.500000 7631.2500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 1192 1867.166666 140000.0000 74.9799
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 409 583.000000 43585.0000 74.7599
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 335 499.000000 37377.5000 74.9048
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 1414 2134.500000 118409.2500 55.4740
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 582 944.000000 70762.5000 74.9603
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 6 6.000000 353.4600 58.9100
MED-99204-OUTPATIENT VISIT, NEW, 45 MINS 1 1.000000 83.2900 83.2900
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 2 2.000000 46.8400 23.4200
OCTH-97167-OT EVAL HIGH COMPLEXITY 2 2.000000 102.1000 51.0500
PSTH-97162-PT EVAL MODERATE COMPLEXITY 3 3.000000 153.1500 51.0500
SCREEN-T1023-SCREENING 48 49.000000 2450.0000 50.0000
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 7 9.000000 459.4500 51.0500
Subtotal (Total Children Is Unduplicated) 2581 6563.166666 445863.7900 67.9342
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EI Services,Class #03
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 13 20.500000 512.5000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 681 3256.860000 162842.8600 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 113 571.000000 40778.0000 71.4151
OCCT-97530HM-OT SESSION BY OT ASST 1 6.000000 343.2000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 135 658.750000 47046.8200 71.4183
PHY-97110HM-PT SESSION BY PT ASST 9 16.000000 914.5600 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 157 717.250000 51240.3400 71.4400
SPL-92508-GROUP SPL SESSION PER CHILD 5 18.000000 249.8400 13.8800
Subtotal (Total Children Is Unduplicated) 1050 5264.360000 303928.1200 57.7332
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Total 57259.776666 2429472.6600 42.4290
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Number of Children (Unduplicated) With at Least One Service 15582
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Center 01
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 197 209.500000 12124.8500 0.0000
P 4 3.000000 111.0000 111.0000
D 2 2.000000 121.4400 0.0000
S 3434 2544.500000 113771.8100 0.0000
H 5768 3974.250000 162623.6300 162623.6300
T 1 0.500000 18.5000 0.0000
28 14.000000 552.4400 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 9434 6747.750000 289323.6700 162734.6300
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 1884 1298.750000 57896.5000 0.0000
---------------------------------------------------------
Total 1884 1298.750000 57896.5000 0.0000
Center 03
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 76 50.750000 1877.7500 0.0000
U 0 0.000000 0.0000 0.0000
B 3194 2153.250000 90841.0000 0.0000
P 2 0.750000 27.7500 27.7500
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
2 3.250000 196.2500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 3274 2208.000000 92942.7500 27.7500
Center 04
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 490 783.750000 28962.7500 0.0000
U 0 0.000000 0.0000 0.0000
B 733 980.500000 38992.5000 0.0000
P 3238 4671.750000 182480.0000 180726.1800
D 1 1.500000 55.5000 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
172 145.000000 9557.8900 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 4634 6582.500000 260048.6400 180726.1800
Center 05
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 15 11.250000 501.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 2310 1501.750000 57926.5000 41575.2400
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
12 8.250000 305.2500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 2337 1521.250000 58732.7500 41575.2400
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 3 3.000000 111.0000 111.0000
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
5005 3757.750000 162762.7500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 5008 3760.750000 162873.7500 111.0000
Center 07
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 9 9.750000 360.7500 0.0000
U 0 0.000000 0.0000 0.0000
B 2035 1740.250000 73773.7000 129.5000
P 1393 1331.500000 56822.7500 56981.5000
D 1 0.250000 9.2500 0.0000
S 4 5.500000 316.5000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
165 118.250000 4501.2500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 3607 3205.500000 135784.2000 57111.0000
Center 09
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 2 1.500000 55.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 332 357.000000 14796.2500 0.0000
P 4181 4460.250000 178881.2500 182507.2500
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 3 6.000000 333.0000 450.0000
0 0.000000 0.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 4518 4824.750000 194066.0000 182957.2500
Center 10
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 104 74.250000 2747.2500 0.0000
U 0 0.000000 0.0000 0.0000
B 2759 2080.750000 81605.5000 0.0000
P 6422 5412.500000 230266.0000 230146.2500
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 2.250000 83.2500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 9288 7569.750000 314702.0000 230146.2500
Center 51
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 5 5.000000 250.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 255 197.000000 10550.8300 0.0000
P 338 246.500000 10386.2500 10385.7500
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
484 373.250000 13810.2500 0.0000
Other 1 1.000000 55.5000 0.0000
---------------------------------------------------------
Total 1083 822.750000 35052.8300 10385.7500
Center 52
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 15 12.750000 743.3900 0.0000
U 0 0.000000 0.0000 0.0000
B 260 259.750000 12169.5800 0.0000
P 1710 1709.500000 79037.2400 78957.8500
D 0 0.000000 0.0000 0.0000
S 5 4.500000 255.5000 75.0000
H 38 35.250000 2497.8700 0.0000
T 0 0.000000 0.0000 0.0000
27 23.750000 1616.0400 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 2055 2045.500000 96319.6200 79032.8500
Center 53
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 6 6.000000 325.3200 0.0000
U 0 0.000000 0.0000 0.0000
B 2318 2144.110000 102468.7300 186.5000
P 1636 1508.000000 68950.2700 68711.0700
D 32 32.750000 2033.5500 0.0000
S 0 0.000000 0.0000 0.0000
H 43 42.750000 3054.0600 0.0000
T 0 0.000000 0.0000 0.0000
2 2.000000 142.8800 0.0000
Other 34 23.750000 903.9400 0.0000
---------------------------------------------------------
Total 4071 3759.360000 177878.7500 68897.5700
Center 54
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 106 99.250000 4119.9700 0.0000
U 0 0.000000 0.0000 0.0000
B 2939 2487.000000 119424.4300 108.4400
P 2886 2377.250000 105120.5700 104483.5900
D 91 90.500000 6172.5400 0.0000
S 0 0.000000 0.0000 0.0000
H 38 37.000000 2621.8400 37.0000
T 0 0.000000 0.0000 0.0000
29 29.000000 1597.7200 0.0000
Other 71 52.750000 2020.6300 27.7500
---------------------------------------------------------
Total 6160 5172.750000 241077.7000 104656.7800
Center 55
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 1575 1314.750000 55126.5000 77.7500
P 2655 2156.750000 86265.2500 89783.6800
D 0 0.000000 0.0000 0.0000
S 2 2.666666 200.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 1 0.750000 27.7500 27.7500
29 18.750000 791.2500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 4262 3493.666666 142410.7500 89889.1800
Center 57
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 199 237.250000 10062.7500 0.0000
P 3493 4009.500000 160300.0000 156793.4000
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 3692 4246.750000 170362.7500 156793.4000