CMS/EIP Fiscal Report Statewide
Services beginning 04/01/2018 ending 06/30/2018 Date of Report:08/10/2018 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 14365 42829.00000 1584210.5000 36.9892
Subtotal (Total Children Is Unduplicated) 14365 42829.00000 1584210.5000 36.9892
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Screening, Eval, and Assessment,Class #02
AUDE-92585-AUD EVOKED RESPONSE (COMP) 1 1.000000 77.1300 77.1300
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 90 144.500000 10837.5000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 61 83.000000 6225.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 16 28.000000 2100.0000 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 131 197.500000 10961.2500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 1273 2064.262000 154729.6500 74.9564
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 575 902.000000 67598.5000 74.9429
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 377 635.500000 47583.5000 74.8757
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 1609 2508.500000 139221.7500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 717 1110.500000 83212.5000 74.9325
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 26 26.000000 1392.3000 53.5500
MED-99204-OUTPATIENT VISIT, NEW, 45 MINS 1 1.000000 75.7200 75.7200
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 7 7.000000 186.2700 26.6100
OCTF-97168-OT RE-EVAL EST PLAN CARE 19 19.000000 969.9500 51.0500
OCTH-97165-OT EVAL LOW COMPLEXITY 3 3.000000 153.1500 51.0500
OCTH-97166-OT EVAL MODERATE COMPLEXITY 16 16.000000 816.8000 51.0500
OCTH-97167-OT EVAL HIGH COMPLEXITY 41 43.000000 2195.1500 51.0500
PSTF-97164-PT RE-EVAL EST PLAN CARE 8 8.000000 408.4000 51.0500
PSTH-97161-PT EVAL LOW COMPLEXITY 1 1.000000 51.0500 51.0500
PSTH-97162-PT EVAL MODERATE COMPLEXITY 10 10.000000 510.5000 51.0500
PSTH-97163-PT EVAL HIGH COMPLEXITY 39 39.000000 1990.9500 51.0500
SCREEN-T1023-SCREENING 81 87.000000 4350.0000 50.0000
SPCH-92522-EVAL OF SPCH SOUND PROD 2 2.000000 102.1000 51.0500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 49 49.000000 2494.9500 50.9173
SPCH-92524-BEHAV & QUAL ANALYSIS OF VOICE AND RES 1 1.000000 51.0500 51.0500
SPCH-92610-EVAL OF ORAL,PHARYNGEAL SWALLOWING FUNC 2 2.000000 89.1000 44.5500
Subtotal (Total Children Is Unduplicated) 2765 8108.262000 547346.7200 67.5048
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 1 1.000000 362.5500 362.5500
COUN-H2019HR-INDIVIDUAL/FAMILY THERAPY 3 4.000000 293.2800 73.3200
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 25 49.000000 1225.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 5862 46504.75000 2324409.0000 49.9822
OCCT-97530-OT SESSION BY LICENSED OT 337 1702.500000 121626.6000 71.4400
OCCT-97530HM-OT SESSION BY OT ASST 190 1053.750000 60274.5000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 313 1884.500000 134057.8600 71.1371
PHY-97110HM-PT SESSION BY PT ASST 133 987.750000 56459.7900 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 575 3711.000000 264713.9200 71.3322
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 31 79.000000 4518.8000 57.2000
SPL-92508-GROUP SPL SESSION PER CHILD 13 44.500000 617.6600 13.8800
Subtotal (Total Children Is Unduplicated) 6727 56021.75000 2968558.9600 52.9894
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Total 106959.012000 5100116.1800 47.6829
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Number of Children (Unduplicated) With at Least One Service 15942
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Center 01
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 43 35.000000 2186.5600 0.0000
U 0 0.000000 0.0000 0.0000
B 8433 5569.750000 225336.1700 0.0000
P 10 9.500000 568.5000 568.5000
D 302 300.000000 18188.5300 0.0000
S 139 130.750000 5354.3500 0.0000
H 1 1.000000 50.0000 0.0000
T 36 33.250000 2023.1400 1855.4500
57 47.000000 2733.8600 0.0000
Other 364 468.750000 27759.8300 0.0000
---------------------------------------------------------
Total 9385 6595.000000 284200.9400 2423.9500
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 1 2.000000 150.0000 0.0000
0 0.000000 0.0000 0.0000
Other 1778 1361.500000 59371.5000 0.0000
---------------------------------------------------------
Total 1779 1363.500000 59521.5000 0.0000
Center 03
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 4 2.000000 74.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 3393 2364.500000 98217.7000 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 1 0.250000 9.2500 0.0000
330 358.000000 23645.5400 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 3728 2724.750000 121946.4900 0.0000
Center 04
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 25 53.750000 1988.7500 0.0000
U 0 0.000000 0.0000 0.0000
B 2113 3490.500000 129372.0500 0.0000
P 913 1148.500000 54952.7600 51163.2500
D 1 1.000000 75.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 2873 12185.500000 621655.9600 250.0000
T 0 0.000000 0.0000 0.0000
818 1011.000000 42075.7400 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 6743 17890.250000 850120.2600 51413.2500
Center 05
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 1 0.500000 18.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 2786 1795.250000 70682.2500 0.0000
P 20 31.000000 1667.0100 1479.0100
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 3.500000 129.5000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 2809 1830.250000 72497.2600 1479.0100
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
5303 3960.500000 167888.7500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 5303 3960.500000 167888.7500 0.0000
Center 07
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 1 2.000000 74.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 33 54.250000 3831.2500 0.0000
P 4512 3678.750000 148866.8000 148866.8000
D 0 0.000000 0.0000 0.0000
S 12 18.250000 1101.2500 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
31 30.500000 1388.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 4589 3783.750000 155261.3000 148866.8000
Center 09
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 414 438.000000 16770.0000 0.0000
P 4133 4236.500000 172098.7500 199351.7500
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
2198 6967.000000 378375.0700 12.5000
Other 153 263.500000 19298.7500 50.0000
---------------------------------------------------------
Total 6898 11905.000000 586542.5700 199414.2500
Center 10
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 41 30.750000 1137.7500 0.0000
U 0 0.000000 0.0000 0.0000
B 9874 8102.000000 342080.5000 0.0000
P 2 4.000000 200.0000 200.0000
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
3450 12357.750000 632155.4400 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 13367 20494.500000 975573.6900 200.0000
Center 51
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 722 540.250000 21403.2500 0.0000
P 3 16.000000 504.3200 90.0000
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
1242 3647.750000 216627.1400 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 1967 4204.000000 238534.7100 90.0000
Center 52
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 160 111.750000 4194.2500 0.0000
P 3174 2915.500000 138381.8600 136781.0600
D 3 3.000000 214.3200 0.0000
S 9 20.000000 1285.0000 0.0000
H 10 9.250000 646.5400 0.0000
T 0 0.000000 0.0000 0.0000
699 1463.750000 87231.2900 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 4055 4523.250000 231953.2600 136781.0600
Center 53
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 2 1.500000 68.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 16 13.500000 647.5000 0.0000
P 3836 3502.500000 157614.7500 157560.0000
D 0 0.000000 0.0000 0.0000
S 10 8.000000 399.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
2068 2137.750000 109238.5000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 5932 5663.250000 267968.2500 157560.0000
Center 54
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 2 3.500000 186.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 2746 2341.250000 97843.0000 0.0000
P 2981 2467.000000 107853.7500 107853.7500
D 3 2.500000 118.5000 0.0000
S 109 116.500000 5447.5000 5382.7500
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
3575 3675.750000 190220.0900 0.0000
Other 1 0.250000 9.2500 0.0000
---------------------------------------------------------
Total 9417 8606.750000 401678.5900 113236.5000
Center 55
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 228 175.000000 6475.0000 0.0000
P 3318 2764.750000 113404.7500 113508.0000
D 0 0.000000 0.0000 0.0000
S 1 0.762000 57.1500 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
4472 4319.500000 261497.5400 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 8019 7260.012000 381434.4400 113508.0000
Center 57
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 842 924.500000 37021.7500 0.0000
P 0 0.000000 0.0000 0.0000
D 0 0.000000 0.0000 0.0000
S 1 4.000000 200.0000 200.0000
H 6 4.500000 249.7500 0.0000
T 0 0.000000 0.0000 0.0000
1854 5221.250000 267522.6700 254274.9100
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 2703 6154.250000 304994.1700 254474.9100