CMS/EIP Fiscal Report Statewide
Services beginning 01/01/2016 ending 03/31/2016 Date of Report:05/12/2016 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 14692 44828.75000 1656225.7500 36.9456
Subtotal (Total Children Is Unduplicated) 14692 44828.75000 1656225.7500 36.9456
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Screening, Eval, and Assessment,Class #02
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 1 1.000000 21.8400 21.8400
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 81 128.500000 9637.5000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 60 85.500000 6412.5000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 22 34.000000 2550.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 49 74.500000 5587.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 136 206.500000 11405.2500 55.2312
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 1283 1925.000000 144075.0000 74.8442
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 424 630.000000 47187.5000 74.9008
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 420 579.500000 43381.4400 74.8601
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 1752 2598.000000 144105.7500 55.4680
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 941 1411.000000 105687.5000 74.9026
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 21 21.000000 850.5000 40.5000
MED-99204-OUTPATIENT VISIT, NEW, 45 MINS 2 2.000000 114.5400 57.2700
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 2 2.000000 44.2800 22.1400
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 2 2.000000 102.1000 51.0500
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 35 35.000000 1786.7500 51.0500
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 10 10.000000 510.5000 51.0500
PSTH-97001-EVAL BY LICENSED PT, INITIAL 20 20.000000 1021.0000 51.0500
SCREEN-T1023-SCREENING 62 67.000000 3350.0000 50.0000
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 43 44.000000 2246.2000 51.0500
SPCH-92524-BEHAV & QUAL ANALYSIS OF
VOICE AND RES 8 9.000000 459.4500 51.0500
Subtotal (Total Children Is Unduplicated) 2852 7885.500000 530537.1000 67.2801
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 2 3.000000 427.1800 142.3933
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 14 20.000000 500.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 4610 33901.00000 1693647.2600 49.9586
OCCT-97530-OT SESSION BY LICENSED OT 265 1418.000000 101222.5800 71.3840
OCCT-97530HM-OT SESSION BY OT ASST 87 316.500000 18103.7200 57.1997
PHY-97110-PT SESSION BY LICENSED PT 283 1583.000000 112901.2000 71.3210
PHY-97110HM-PT SESSION BY PT ASST 73 355.750000 20303.5900 57.0726
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 602 3705.250000 263719.4000 71.1745
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 30 58.500000 3346.2000 57.2000
SPL-92508-GROUP SPL SESSION PER CHILD 5 21.500000 267.3800 12.4363
Subtotal (Total Children Is Unduplicated) 5386 41382.50000 2214438.5100 53.5115
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Total 94096.750000 4401201.3600 46.7731
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Number of Children (Unduplicated) With at Least One Service 15549
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Center 01
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 16 6.500000 231.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 8200 5316.750000 195930.6900 9.2500
P 27 27.000000 1458.2400 1458.2400
D 2 1.750000 64.7500 0.0000
S 306 259.750000 9610.7500 0.0000
H 0 0.000000 0.0000 0.0000
T 4 4.000000 221.4400 221.4400
13 6.750000 249.7500 0.0000
Other 11 8.500000 314.5000 0.0000
---------------------------------------------------------
Total 8579 5631.000000 208081.6200 1688.9300
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 18 18.000000 1228.7600 541.4700
68 70.000000 4515.4400 0.0000
Other 1824 1377.750000 56025.0000 0.0000
---------------------------------------------------------
Total 1910 1465.750000 61769.2000 541.4700
Center 03
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 4 3.500000 213.5500 0.0000
U 0 0.000000 0.0000 0.0000
B 1751 1128.000000 44831.7500 0.0000
P 2539 1650.750000 69453.5000 69772.8360
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 53 52.500000 3730.2100 0.0000
T 0 0.000000 0.0000 0.0000
6 2.750000 149.1900 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 4353 2837.500000 118378.2000 69772.8360
Center 04
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 159 214.500000 9057.5000 0.0000
P 3052 4458.250000 173840.6400 173893.7600
D 1 0.750000 27.7500 0.0000
S 2 4.250000 157.2500 0.0000
H 2321 8119.000000 408962.2400 0.0000
T 0 0.000000 0.0000 0.0000
410 579.000000 35555.2000 0.0000
Other 1 1.000000 51.0500 0.0000
---------------------------------------------------------
Total 5946 13376.750000 627651.6300 173893.7600
Center 05
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 3 1.500000 55.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 2140 1390.500000 56690.5000 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
1 1.000000 51.0500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 2144 1393.000000 56797.0500 0.0000
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
4895 3353.750000 139524.7700 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 4895 3353.750000 139524.7700 0.0000
Center 07
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 2 1.000000 37.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 9 5.500000 203.5000 64.7500
P 5618 4291.750000 174885.7500 174867.2500
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
118 174.000000 8688.5300 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 5747 4472.250000 183814.7800 174932.0000
Center 09
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 1 2.750000 101.7500 0.0000
U 0 0.000000 0.0000 0.0000
B 98 109.750000 5588.0000 58.5000
P 4514 4535.250000 198449.4400 198449.4400
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
1721 5414.000000 294082.0200 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 6334 10061.750000 498221.2100 198507.9400
Center 10
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 16 12.250000 453.2500 0.0000
U 0 0.000000 0.0000 0.0000
B 4770 3903.250000 181288.2500 0.0000
P 2902 1941.000000 71893.0000 71893.0000
D 1 0.500000 18.5000 18.5000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
2771 9190.250000 478821.8000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 10460 15047.250000 732474.8000 71911.5000
Center 51
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 18 12.750000 471.7500 0.0000
U 0 0.000000 0.0000 0.0000
B 2944 1957.250000 74936.7500 0.0000
P 0 0.000000 0.0000 0.0000
D 17 10.500000 388.5000 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
909 2530.000000 152602.3800 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 3888 4510.500000 228399.3800 0.0000
Center 52
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 5 10.000000 750.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 2184 2022.250000 94874.0000 35.0000
P 807 669.250000 27206.7000 27169.7000
D 30 9.750000 395.1900 0.0000
S 1 0.250000 9.2500 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
882 1489.500000 91831.6800 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 3909 4201.000000 215066.8200 27204.7000
Center 53
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 152 114.250000 4374.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 2240 2067.250000 89376.7500 111.0000
P 2054 2002.750000 93589.7500 93534.2500
D 0 0.000000 0.0000 0.0000
S 5 8.750000 551.7500 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
1459 1520.500000 78334.0900 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 5910 5713.500000 266226.3400 93645.2500
Center 54
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 2 2.000000 74.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 5484 4709.750000 202608.5500 0.0000
P 118 120.750000 6270.5000 6270.5000
D 1 1.000000 37.0000 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
2954 2923.000000 147460.1600 0.0000
Other 2 3.000000 111.0000 0.0000
---------------------------------------------------------
Total 8561 7759.500000 356561.2100 6270.5000
Center 55
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 14 12.500000 538.5000 0.0000
P 3285 3356.000000 142981.0000 142914.2500
D 0 0.000000 0.0000 0.0000
S 2 2.250000 83.2500 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
3169 2900.000000 191298.0200 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 6470 6270.750000 334900.7700 142914.2500
Center 57
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 3987 3884.000000 157210.7500 111.0000
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 1 1.000000 75.0000 0.0000
T 4 11.000000 537.0000 500.0000
1351 4106.500000 215510.8300 215010.8300
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 5343 8002.500000 373333.5800 215621.8300