CMS/EIP Fiscal Report Statewide
Services beginning 01/01/2018 ending 03/31/2018 Date of Report:05/05/2018 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 15359 47030.50000 1739600.0000 36.9888
Subtotal (Total Children Is Unduplicated) 15359 47030.50000 1739600.0000 36.9888
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 112 188.000000 14100.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 62 93.000000 6900.0000 74.1935
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 24 40.500000 3037.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 72 113.000000 8475.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 141 233.000000 12833.0000 55.0773
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 1555 2391.000000 179215.2900 74.9541
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 663 1018.000000 76325.6500 74.9761
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 463 733.000000 54950.0000 74.9659
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 1881 2826.500000 156726.4500 55.4489
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 950 1425.500000 106838.5000 74.9481
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 53 54.000000 2891.7000 53.5500
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 8 8.000000 212.8800 26.6100
OCTF-97168-OT RE-EVAL EST PLAN CARE 14 14.000000 714.7000 51.0500
OCTH-97166-OT EVAL MODERATE COMPLEXITY 26 26.000000 1327.3000 51.0500
OCTH-97167-OT EVAL HIGH COMPLEXITY 59 66.000000 3369.3000 51.0500
PSTF-97164-PT RE-EVAL EST PLAN CARE 10 10.000000 510.5000 51.0500
PSTH-97162-PT EVAL MODERATE COMPLEXITY 7 7.000000 357.3500 51.0500
PSTH-97163-PT EVAL HIGH COMPLEXITY 65 65.000000 3318.2500 51.0500
SCREEN-T1023-SCREENING 36 38.000000 1900.0000 50.0000
SPCH-92521-EVAL OF SPEECH FLUENCY 1 1.000000 51.0500 51.0500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 73 73.000000 3726.6500 51.0500
SPCH-92524-BEHAV & QUAL ANALYSIS OF
VOICE AND RES 4 4.000000 204.2000 51.0500
SPCH-92610-EVAL OF ORAL,PHARYNGEAL SWALLOWING FUNC 1 1.000000 44.5500 44.5500
Subtotal (Total Children Is Unduplicated) 3304 9428.500000 638029.8200 67.6703
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EI Services,Class #03
COUN-H2019HR-INDIVIDUAL/FAMILY THERAPY 1 7.000000 513.2400 73.3200
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 7 16.000000 400.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 5424 41820.00000 2090504.0000 49.9881
OCCT-97530-OT SESSION BY LICENSED OT 316 1708.750000 121524.6200 71.1190
OCCT-97530HM-OT SESSION BY OT ASST 166 991.750000 56728.1000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 283 1757.000000 125505.8000 71.4319
PHY-97110HM-PT SESSION BY PT ASST 111 799.000000 45670.8400 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 574 3716.000000 264736.2000 71.2422
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 10 34.500000 1973.4000 57.2000
SPL-92508-GROUP SPL SESSION PER CHILD 11 32.000000 444.1600 13.8800
Subtotal (Total Children Is Unduplicated) 6231 50882.00000 2708000.3600 53.2212
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Total 107341.000000 5085630.1800 47.3783
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Number of Children (Unduplicated) With at Least One Service 16550
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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 8338 5603.250000 221327.2900 0.0000
P 224 273.000000 17102.7000 17102.7000
D 194 197.000000 12458.4100 0.0000
S 136 133.250000 7658.9300 0.0000
H 0 0.000000 0.0000 0.0000
T 2 1.500000 68.5000 0.0000
76 50.500000 2203.9400 0.0000
Other 275 361.000000 22159.9500 0.0000
---------------------------------------------------------
Total 9245 6619.500000 282979.7200 17102.7000
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 1877 1417.250000 62099.7500 0.0000
---------------------------------------------------------
Total 1877 1417.250000 62099.7500 0.0000
Center 03
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 36 25.000000 981.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 3251 2309.250000 96927.6900 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
38 26.000000 1103.0000 0.0000
Other 2 0.500000 18.5000 0.0000
---------------------------------------------------------
Total 3327 2360.750000 99030.6900 0.0000
Center 04
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 17 15.000000 555.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 303 459.750000 17158.8000 0.0000
P 3307 5185.250000 203697.5600 203833.0850
D 0 0.000000 0.0000 0.0000
S 1 1.500000 55.5000 0.0000
H 2285 9435.000000 483944.8300 0.0000
T 0 0.000000 0.0000 0.0000
423 653.250000 43637.1200 0.0000
Other 1 1.500000 55.5000 0.0000
---------------------------------------------------------
Total 6337 15751.250000 749104.3100 203833.0850
Center 05
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 3 2.500000 92.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 2863 1884.250000 75622.5000 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
2 1.000000 37.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 2868 1887.750000 75752.0000 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
5470 4134.500000 175955.8800 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 5470 4134.500000 175955.8800 0.0000
Center 07
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 2 2.250000 159.2500 0.0000
U 0 0.000000 0.0000 0.0000
B 35 30.500000 1489.5000 0.0000
P 5141 3938.000000 161147.0000 161147.0000
D 1 0.250000 9.2500 0.0000
S 3 2.750000 177.7500 0.0000
H 1 2.250000 83.2500 0.0000
T 0 0.000000 0.0000 0.0000
22 27.500000 1123.5000 0.0000
Other 1 1.000000 37.0000 0.0000
---------------------------------------------------------
Total 5206 4004.500000 164226.5000 161147.0000
Center 09
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 28 29.750000 1150.9500 50.0000
P 3861 4189.000000 174916.2500 175826.7520
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
2069 6493.500000 355190.2100 0.0000
Other 204 327.000000 23988.7500 0.0000
---------------------------------------------------------
Total 6162 11039.250000 555246.1600 175876.7520
Center 10
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 8 3.250000 120.2500 0.0000
U 0 0.000000 0.0000 0.0000
B 10938 8742.000000 365211.0000 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
3309 11633.000000 596083.1200 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 14255 20378.250000 961414.3700 0.0000
Center 51
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 4 1.500000 62.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 2081 1237.250000 47647.2500 0.0000
P 7 18.000000 263.5700 171.0500
D 13 6.250000 231.2500 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
1118 3146.750000 188686.1900 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 3223 4409.750000 236890.2600 171.0500
Center 52
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 23 15.750000 557.0000 0.0000
P 3262 3023.000000 141423.7900 140259.1100
D 17 16.250000 1146.6200 0.0000
S 22 40.500000 2827.5000 0.0000
H 26 23.500000 1537.0500 0.0000
T 0 0.000000 0.0000 0.0000
703 1500.750000 89081.3500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 4053 4619.750000 236573.3100 140259.1100
Center 53
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 2 2.000000 74.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 348 233.000000 8621.0000 0.0000
P 3312 3188.250000 144028.2500 144028.2500
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
1852 1964.500000 101552.6800 0.0000
Other 4 3.250000 120.2500 0.0000
---------------------------------------------------------
Total 5518 5391.000000 254396.1800 144028.2500
Center 54
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 62 61.250000 2507.2500 0.0000
U 0 0.000000 0.0000 0.0000
B 4107 3115.750000 128218.0000 0.0000
P 1039 989.750000 48532.7500 48505.0000
D 2 1.250000 59.2500 0.0000
S 229 258.500000 15056.5000 15047.2500
H 91 85.500000 3163.5000 3163.5000
T 0 0.000000 0.0000 0.0000
4374 4478.750000 225701.8500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 9904 8990.750000 423239.1000 66715.7500
Center 55
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 6 7.750000 286.7500 0.0000
P 3842 3419.750000 141004.7500 140927.7500
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
4237 4092.250000 251722.6900 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 8085 7519.750000 393014.1900 140927.7500
Center 57
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 2961 3190.500000 126499.7500 0.0000
P 48 43.000000 2528.9400 2528.9400
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 4 3.000000 166.5000 0.0000
T 1 4.000000 200.0000 200.0000
1695 5576.500000 286312.5700 286162.4500
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 4709 8817.000000 415707.7600 288891.3900