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:Program Patients
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 15282 46417.00000 1716966.5000 36.9900
Subtotal (Total Children Is Unduplicated) 15282 46417.00000 1716966.5000 36.9900
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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 111 181.500000 13612.5000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 67 93.500000 7012.5000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 19 33.500000 2512.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 77 138.000000 10350.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 158 243.000000 13486.5000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 1594 2584.186000 193704.2400 74.9575
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 749 1165.000000 87336.6500 74.9671
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 474 782.500000 58608.5000 74.8990
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 2022 3130.000000 173687.2500 55.4911
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 894 1377.000000 103200.0000 74.9455
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 27 27.000000 1445.8500 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 87 93.000000 4650.0000 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) 3421 10050.18600 679778.7600 67.6384
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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 5864 46507.75000 2324559.0000 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 576 3712.000000 264785.3600 71.3323
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) 6730 56025.75000 2968780.4000 52.9896
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Total 112492.936000 5365525.6600 47.6966
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Number of Children (Unduplicated) With at Least One Service 16878
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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 8738 5857.250000 237647.9200 0.0000
P 10 9.500000 568.5000 568.5000
D 302 300.000000 18188.5300 0.0000
S 140 131.000000 5363.6000 0.0000
H 1 1.000000 50.0000 0.0000
T 36 33.250000 2023.1400 1855.4500
59 49.500000 2883.3600 0.0000
Other 391 509.750000 30347.3300 0.0000
---------------------------------------------------------
Total 9720 6926.250000 299258.9400 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 1963 1522.500000 66561.7500 0.0000
---------------------------------------------------------
Total 1964 1524.500000 66711.7500 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 3605 2584.500000 107380.4500 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
360 410.500000 27300.2900 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 3970 2997.250000 134763.9900 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 2247 3789.750000 140548.0500 0.0000
P 1053 1323.500000 64042.2600 60252.7500
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
895 1136.500000 47478.0400 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 7094 18490.000000 875788.0600 60502.7500
Center 05
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 1 0.500000 18.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 2988 1979.750000 78895.7500 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 3011 2014.750000 80710.7600 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
5493 4159.250000 177457.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 5493 4159.250000 177457.0000 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 37 61.500000 4327.5000 0.0000
P 4808 4036.250000 165440.0500 165440.0500
D 0 0.000000 0.0000 0.0000
S 15 22.500000 1332.5000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
35 38.500000 1912.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 4896 4160.750000 173086.0500 165440.0500
Center 09
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 439 480.750000 18351.7500 0.0000
P 4373 4638.000000 190885.2500 218138.2500
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
2214 6990.500000 380137.5700 12.5000
Other 213 359.500000 26333.0000 50.0000
---------------------------------------------------------
Total 7239 12468.750000 615707.5700 218200.7500
Center 10
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 42 31.250000 1156.2500 0.0000
U 0 0.000000 0.0000 0.0000
B 10313 8572.750000 364196.5000 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 13807 20965.750000 997708.1900 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 848 629.750000 25171.7500 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
1270 3675.750000 218727.1400 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 2121 4321.500000 244403.2100 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 163 114.000000 4277.5000 0.0000
P 3355 3131.500000 148897.6500 147296.8500
D 3 3.000000 214.3200 0.0000
S 9 20.000000 1285.0000 0.0000
H 11 10.250000 734.6900 0.0000
T 0 0.000000 0.0000 0.0000
710 1484.250000 88729.7900 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 4251 4763.000000 244138.9500 147296.8500
Center 53
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 2 1.500000 68.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 17 13.750000 656.7500 9.2500
P 4163 3847.750000 174021.0000 173966.2500
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
2099 2181.500000 111831.2500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 6291 6052.500000 286976.5000 173975.5000
Center 54
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 2 3.500000 186.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 3079 2694.250000 113321.2500 0.0000
P 3256 2757.750000 121370.7500 121370.7500
D 3 2.500000 118.5000 0.0000
S 121 132.500000 6343.5000 6278.7500
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
3660 3807.250000 198200.8400 0.0000
Other 1 0.250000 9.2500 0.0000
---------------------------------------------------------
Total 10122 9398.000000 439550.5900 127649.5000
Center 55
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 250 201.750000 7464.7500 0.0000
P 3761 3317.162000 138220.1500 138323.4000
D 0 0.000000 0.0000 0.0000
S 2 1.524000 114.3000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
4575 4523.000000 275840.4800 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 8588 8043.436000 421639.6800 138323.4000
Center 57
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 843 926.500000 37095.7500 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
1900 5272.250000 270078.9200 254796.9100
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 2750 6207.250000 307624.4200 254996.9100