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:Program Patients
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 15569 47961.75000 1773422.9400 36.9758
Subtotal (Total Children Is Unduplicated) 15569 47961.75000 1773422.9400 36.9758
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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 108 162.500000 12087.5000 74.3846
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 57 89.000000 6675.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 36 45.500000 3412.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 93 146.000000 10950.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 147 236.000000 13098.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 1478 2207.000000 165445.0000 74.9638
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 661 927.500000 69508.2500 74.9415
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 487 698.000000 52350.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 1811 2712.500000 150391.2700 55.4438
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 1002 1475.500000 110611.0400 74.9651
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 37 37.000000 1929.1500 52.1392
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 78 82.000000 4100.0000 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) 3278 8965.500000 607793.9000 67.7925
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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 5727 41158.75000 2057397.0000 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) 6542 49279.00000 2619387.9400 53.1542
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Total 106206.250000 5000604.7800 47.0839
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Number of Children (Unduplicated) With at Least One Service 16556
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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 8759 5763.250000 219969.0200 0.0000
P 12 14.500000 883.2500 883.2500
D 195 195.750000 11827.2800 0.0000
S 341 385.250000 26272.0400 0.0000
H 1 1.500000 112.5000 0.0000
T 0 0.000000 0.0000 0.0000
22 15.000000 568.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 9416 6448.250000 264322.0300 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 2049 1567.750000 69574.2500 0.0000
---------------------------------------------------------
Total 2052 1570.500000 69729.9300 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 1069 692.250000 27117.5000 100.0000
P 2329 1520.000000 63376.5000 46551.2750
D 0 0.000000 0.0000 0.0000
S 6 5.250000 194.2500 0.0000
H 78 72.000000 5102.9000 0.0000
T 0 0.000000 0.0000 0.0000
107 68.250000 3128.2900 0.0000
Other 71 56.000000 2215.0000 0.0000
---------------------------------------------------------
Total 3660 2413.750000 101134.4400 46651.2750
Center 04
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 1 1.000000 55.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 795 998.750000 44354.7500 0.0000
P 3449 5166.500000 203352.1400 203316.6500
D 0 0.000000 0.0000 0.0000
S 2 2.000000 74.0000 0.0000
H 2254 8863.000000 447888.7500 228.6400
T 0 0.000000 0.0000 0.0000
699 1056.750000 57824.5000 0.0000
Other 2 6.500000 464.3600 178.6000
---------------------------------------------------------
Total 7202 16094.500000 754014.0000 203723.8900
Center 05
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 1 1.000000 37.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 3086 2137.500000 87294.0000 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 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 3087 2138.500000 87331.0000 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
9402 7689.500000 363723.7100 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 9402 7689.500000 363723.7100 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 5990 4474.500000 184047.2500 184001.0000
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
35 60.750000 2865.7500 0.0000
Other 1 1.000000 37.0000 0.0000
---------------------------------------------------------
Total 6044 4547.500000 187366.2500 184001.0000
Center 09
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 2 3.500000 129.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 229 209.250000 8238.2500 27.7500
P 4077 4080.000000 173697.7700 173697.7700
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
2006 6447.500000 358067.1400 0.0000
Other 183 264.500000 19578.5000 0.0000
---------------------------------------------------------
Total 6497 11004.750000 559711.1600 173725.5200
Center 10
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 548 383.500000 14189.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 7466 5617.750000 239538.0000 0.0000
P 1864 1403.750000 64433.7500 64433.7500
D 1 0.250000 9.2500 0.0000
S 70 41.000000 1669.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
2666 9351.000000 483038.7400 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 12615 16797.250000 802878.2400 64433.7500
Center 51
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 6 6.500000 278.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 2431 1561.000000 60814.0000 0.0000
P 3 11.000000 785.8400 785.8400
D 9 4.000000 148.0000 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
773 2346.750000 140217.9700 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 3222 3929.250000 202244.3100 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 287 207.500000 8593.7500 37.0000
P 3105 2840.750000 130718.7100 129795.8800
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
637 1454.000000 87491.4600 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 4079 4547.000000 229641.7000 129879.7800
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 4047 3801.000000 170684.2500 170684.2500
D 0 0.000000 0.0000 0.0000
S 476 344.500000 12679.4400 12623.9400
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
1354 1407.250000 73282.6100 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 6010 5690.000000 263288.5500 183308.1900
Center 54
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 2 1.500000 68.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 4190 3394.250000 140417.5000 0.0000
P 2738 2450.750000 115118.0000 115053.2500
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 17 11.000000 407.0000 407.0000
2675 2764.750000 142952.3100 0.0000
Other 1 0.750000 27.7500 0.0000
---------------------------------------------------------
Total 9623 8623.000000 398991.0600 115460.2500
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 3970 3632.250000 149682.0000 149682.0000
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
3847 3644.500000 222466.8300 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 7819 7280.500000 372287.5800 149682.0000
Center 57
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 32 29.750000 1100.7500 0.0000
U 0 0.000000 0.0000 0.0000
B 2388 2322.000000 91389.0000 0.0000
P 866 841.000000 34968.7500 34968.7500
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
1234 4238.750000 216463.8200 214848.5700
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 4522 7432.000000 343940.8200 249817.3200