CMS/EIP Fiscal Report Statewide
Services beginning 01/01/2017 ending 03/31/2017 Date of Report:05/05/2017 Page: 1
List order: No List
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 14584 44131.00000 1631814.6900 36.9766
Subtotal (Total Children Is Unduplicated) 14584 44131.00000 1631814.6900 36.9766
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Screening, Eval, and Assessment,Class #02
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 1 1.000000 8.2600 8.2600
AUDE-92568-ACOUSTIC REFLEX TESTING (MEMR) 1 1.000000 9.0600 9.0600
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 1 1.000000 18.5500 18.5500
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 90 132.500000 9937.5000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 50 77.500000 5812.5000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 31 37.000000 2775.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 84 132.000000 9900.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 125 197.500000 10961.2500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 1177 1748.000000 131020.0000 74.9542
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 534 745.000000 55820.7500 74.9272
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 381 557.500000 41812.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 1427 2142.500000 118756.2700 55.4288
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 799 1171.000000 87800.0000 74.9787
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 36 36.000000 1875.6000 52.1000
MED-99204-OUTPATIENT VISIT, NEW, 45 MINS 1 1.000000 75.7200 75.7200
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 7 7.000000 181.8000 25.9714
OCTF-97168-OT RE-EVAL EST PLAN CARE 10 11.000000 561.5500 51.0500
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 4 4.000000 204.2000 51.0500
OCTH-97165-OT EVAL LOW COMPLEXITY 2 2.000000 102.1000 51.0500
OCTH-97166-OT EVAL MODERATE COMPLEXITY 8 8.000000 408.4000 51.0500
OCTH-97167-OT EVAL HIGH COMPLEXITY 30 31.000000 1582.5500 51.0500
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 1 1.000000 51.0500 51.0500
PSTF-97164-PT RE-EVAL EST PLAN CARE 6 6.000000 306.3000 51.0500
PSTH-97001-EVAL BY LICENSED PT, INITIAL 2 2.000000 102.1000 51.0500
PSTH-97161-PT EVAL LOW COMPLEXITY 3 3.000000 153.1500 51.0500
PSTH-97163-PT EVAL HIGH COMPLEXITY 30 30.000000 1531.5000 51.0500
SCREEN-T1023-SCREENING 74 78.000000 3900.0000 50.0000
SPCH-92521-EVAL OF SPEECH FLUENCY 1 1.000000 51.0500 51.0500
SPCH-92522-EVAL OF SPCH SOUND PROD 1 1.000000 51.0500 51.0500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 31 31.000000 1582.5500 51.0500
SPCH-92524-BEHAV & QUAL ANALYSIS OF
VOICE AND RES 5 5.000000 255.2500 51.0500
Subtotal (Total Children Is Unduplicated) 2632 7201.500000 487607.5600 67.7092
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 2 2.000000 315.2600 157.6300
COUN-H2019HR-INDIVIDUAL/FAMILY THERAPY 4 7.000000 513.2400 73.3200
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 9 23.000000 575.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 5722 41135.75000 2056247.0000 49.9869
OCCT-97530-OT SESSION BY LICENSED OT 302 1744.000000 124505.6800 71.3909
OCCT-97530HM-OT SESSION BY OT ASST 128 637.250000 36450.7000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 330 1875.500000 133950.0000 71.4210
PHY-97110HM-PT SESSION BY PT ASST 73 469.000000 26808.0400 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 572 3330.000000 237858.7600 71.4291
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 6 13.000000 743.6000 57.2000
SPL-92508-GROUP SPL SESSION PER CHILD 7 19.500000 270.6600 13.8800
Subtotal (Total Children Is Unduplicated) 6537 49256.00000 2618237.9400 53.1557
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Total 100588.500000 4737660.1900 47.0994
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Number of Children (Unduplicated) With at Least One Service 15557
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Center 01
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 86 73.000000 4689.9400 0.0000
U 0 0.000000 0.0000 0.0000
B 8307 5391.250000 205731.0200 0.0000
P 12 14.500000 883.2500 883.2500
D 194 194.250000 11741.2400 0.0000
S 302 331.500000 22740.0400 0.0000
H 1 1.500000 112.5000 0.0000
T 0 0.000000 0.0000 0.0000
20 14.000000 531.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 8922 6020.000000 246428.9900 883.2500
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
3 2.750000 155.6800 0.0000
Other 1845 1383.500000 60965.0000 0.0000
---------------------------------------------------------
Total 1848 1386.250000 61120.6800 0.0000
Center 03
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 983 608.750000 23915.0000 100.0000
P 2155 1341.250000 55341.7500 39978.0250
D 0 0.000000 0.0000 0.0000
S 5 4.250000 157.2500 0.0000
H 78 72.000000 5102.9000 0.0000
T 0 0.000000 0.0000 0.0000
105 66.750000 3072.7900 0.0000
Other 60 48.500000 1937.5000 0.0000
---------------------------------------------------------
Total 3386 2141.500000 89527.1900 40078.0250
Center 04
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 1 1.000000 55.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 741 930.750000 41169.0000 0.0000
P 3269 4847.750000 190520.3900 190484.9000
D 0 0.000000 0.0000 0.0000
S 2 2.000000 74.0000 0.0000
H 2251 8850.000000 447238.7500 228.6400
T 0 0.000000 0.0000 0.0000
653 1018.000000 55523.2000 0.0000
Other 2 6.500000 464.3600 178.6000
---------------------------------------------------------
Total 6919 15656.000000 735045.2000 190892.1400
Center 05
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 1 1.000000 37.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 2834 1909.250000 77157.7500 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 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 2835 1910.250000 77194.7500 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
9177 7466.750000 353293.9600 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 9177 7466.750000 353293.9600 0.0000
Center 07
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 2 0.750000 27.7500 0.0000
U 0 0.000000 0.0000 0.0000
B 13 9.250000 342.2500 0.0000
P 5534 3973.000000 160105.0000 160058.7500
D 0 0.000000 0.0000 0.0000
S 3 1.250000 46.2500 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
32 55.750000 2606.7500 0.0000
Other 1 1.000000 37.0000 0.0000
---------------------------------------------------------
Total 5585 4041.000000 163165.0000 160058.7500
Center 09
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 2 3.500000 129.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 220 191.750000 7419.7500 27.7500
P 3857 3758.500000 157651.7700 157651.7700
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
2005 6446.500000 357992.1400 0.0000
Other 142 213.500000 15802.2500 0.0000
---------------------------------------------------------
Total 6226 10613.750000 538995.4100 157679.5200
Center 10
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 529 368.000000 13616.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 7035 5144.750000 217016.5000 0.0000
P 1709 1224.250000 54837.0000 54837.0000
D 1 0.250000 9.2500 0.0000
S 61 33.500000 1391.5000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
2662 9345.000000 482816.7400 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 11997 16115.750000 769686.9900 54837.0000
Center 51
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 6 6.500000 278.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 2315 1476.250000 57329.0000 0.0000
P 3 11.000000 785.8400 785.8400
D 8 3.250000 120.2500 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
765 2338.250000 139629.2200 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 3097 3835.250000 198142.8100 785.8400
Center 52
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 265 188.750000 7672.0000 37.0000
P 2843 2546.000000 116675.4600 115715.6300
D 18 16.250000 1111.9500 0.0000
S 5 5.750000 212.7500 0.0000
H 27 22.750000 1513.0800 46.9000
T 0 0.000000 0.0000 0.0000
619 1419.500000 84903.9600 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 3777 4199.000000 212089.2000 115799.5300
Center 53
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 133 137.250000 6642.2500 0.0000
P 3754 3492.750000 156570.7500 156570.7500
D 0 0.000000 0.0000 0.0000
S 447 315.750000 11615.6900 11615.6900
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
1341 1388.750000 71963.3600 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 5675 5334.500000 246792.0500 168186.4400
Center 54
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 2 1.500000 68.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 3796 3004.500000 124093.0000 0.0000
P 2545 2232.000000 104203.0000 104138.2500
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 16 10.000000 370.0000 370.0000
2632 2696.250000 138873.3100 0.0000
Other 1 0.750000 27.7500 0.0000
---------------------------------------------------------
Total 8992 7945.000000 367635.5600 104508.2500
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 3.750000 138.7500 0.0000
P 3603 3143.500000 127746.2500 127746.2500
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
3793 3546.000000 215699.0800 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 7398 6693.250000 343584.0800 127746.2500
Center 57
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 32 29.750000 1100.7500 0.0000
U 0 0.000000 0.0000 0.0000
B 2286 2188.500000 85959.0000 0.0000
P 818 788.750000 32460.2500 32460.2500
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 2 0.500000 18.5000 0.0000
T 0 0.000000 0.0000 0.0000
1224 4222.750000 215419.8200 214121.0700
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 4362 7230.250000 334958.3200 246581.3200