CMS/EIP Fiscal Report Statewide
Services beginning 10/01/2018 ending 12/31/2018 Date of Report:02/06/2019 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 14204 38950.25000 1439726.0000 36.9632
Subtotal (Total Children Is Unduplicated) 14204 38950.25000 1439726.0000 36.9632
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Screening, Eval, and Assessment,Class #02
AUDE-92557-COMP AUDIO THRESHOLD EVAL/SPCH RECOG 1 3.000000 51.5500 17.1833
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 107 172.000000 12900.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 58 87.000000 6525.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 17 30.000000 2250.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 54 82.000000 6150.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 121 192.500000 10683.7500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 1298 2079.500000 155962.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 629 993.500000 74512.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 267 458.500000 34387.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 1738 2746.500000 152369.7500 55.4778
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 802 1290.000000 96712.5000 74.9709
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 19 19.000000 1119.2900 58.9100
MED-99204-OUTPATIENT VISIT, NEW, 45 MINS 6 6.000000 499.7400 83.2900
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 9 9.000000 210.7800 23.4200
MED-99214-OUTPATIENT VISIT, EST, 25 MINS 1 1.000000 36.4900 36.4900
OCTF-97168-OT RE-EVAL EST PLAN CARE 12 12.000000 612.6000 51.0500
OCTH-97166-OT EVAL MODERATE COMPLEXITY 15 15.000000 765.7500 51.0500
OCTH-97167-OT EVAL HIGH COMPLEXITY 37 37.000000 1888.8500 51.0500
PSTF-97164-PT RE-EVAL EST PLAN CARE 5 5.000000 255.2500 51.0500
PSTH-97162-PT EVAL MODERATE COMPLEXITY 6 6.000000 306.3000 51.0500
PSTH-97163-PT EVAL HIGH COMPLEXITY 40 40.000000 2042.0000 51.0500
SCREEN-T1023-SCREENING 47 48.000000 2400.0000 50.0000
SPCH-92522-EVAL OF SPCH SOUND PROD 1 1.000000 51.0500 51.0500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 35 37.000000 1888.8500 51.0500
SPCH-92524-BEHAV & QUAL ANALYSIS OF VOICE AND RES 7 7.000000 357.3500 51.0500
Subtotal (Total Children Is Unduplicated) 2755 8377.500000 564939.3500 67.4353
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EI Services,Class #03
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 23 41.750000 1043.7500 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 6726 50727.00000 2535054.6400 49.9745
OCCT-97530-OT SESSION BY LICENSED OT 429 2106.250000 150470.5000 71.4400
OCCT-97530HM-OT SESSION BY OT ASST 197 1139.743010 65164.7000 57.1749
PHY-97110-PT SESSION BY LICENSED PT 404 2227.250000 159058.1800 71.4146
PHY-97110HM-PT SESSION BY PT ASST 102 603.750000 34510.3500 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 664 3663.750000 261677.5600 71.4234
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 1 12.000000 686.4000 57.2000
SPL-92508-GROUP SPL SESSION PER CHILD 7 17.000000 235.9600 13.8800
Subtotal (Total Children Is Unduplicated) 7657 60538.49301 3207902.0400 52.9895
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Total 107866.243010 5212567.3900 48.3244
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Number of Children (Unduplicated) With at Least One Service 16017
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Center 01
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 600 432.250000 17890.0900 0.0000
U 0 0.000000 0.0000 0.0000
B 700 769.750000 46448.6200 0.0000
P 6132 3936.000000 147316.3300 144406.7800
D 120 119.000000 5885.8300 0.0000
S 11 14.500000 861.1300 0.0000
H 2 1.000000 37.0000 37.0000
T 1 0.750000 27.7500 0.0000
8 2.250000 83.2500 0.0000
Other 377 501.500000 30231.4500 0.0000
---------------------------------------------------------
Total 7951 5777.000000 248781.4500 144443.7800
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 1528 1119.500000 50200.2500 0.0000
---------------------------------------------------------
Total 1528 1119.500000 50200.2500 0.0000
Center 03
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 92 67.500000 3069.2500 0.0000
U 0 0.000000 0.0000 0.0000
B 2657 1902.250000 82527.0000 0.0000
P 0 0.000000 0.0000 0.0000
D 0 0.000000 0.0000 0.0000
S 2 1.750000 64.7500 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
22 37.000000 2564.7500 0.0000
Other 1 0.500000 18.5000 0.0000
---------------------------------------------------------
Total 2774 2009.000000 88244.2500 0.0000
Center 04
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 8 8.500000 314.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 1146 1666.000000 64344.7500 0.0000
P 2608 4065.750000 160912.3800 158214.8900
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 2542 10804.500000 549833.7000 0.0000
T 0 0.000000 0.0000 0.0000
395 585.750000 37872.7200 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 6699 17130.500000 813278.0500 158214.8900
Center 05
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 65 46.250000 1711.2500 0.0000
U 0 0.000000 0.0000 0.0000
B 2137 1412.750000 55546.5000 0.0000
P 2 2.500000 187.5000 187.5000
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
1 0.750000 27.7500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 2205 1462.250000 57473.0000 187.5000
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
11703 10070.000000 483214.3900 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 11703 10070.000000 483214.3900 0.0000
Center 07
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 13 9.500000 351.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 40 36.000000 1421.0000 0.0000
P 3565 3057.750000 129078.3900 129013.6400
D 0 0.000000 0.0000 0.0000
S 8 8.000000 400.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
31 21.250000 880.7500 0.0000
Other 2 1.000000 37.0000 0.0000
---------------------------------------------------------
Total 3659 3133.500000 132168.6400 129013.6400
Center 09
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 189 222.750000 8241.7500 0.0000
U 0 0.000000 0.0000 0.0000
B 1700 1599.250000 62514.0000 124.5000
P 2889 2918.500000 120148.2500 120038.3300
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
2387 7390.000000 406975.9000 0.0000
Other 160 269.000000 19659.2500 0.0000
---------------------------------------------------------
Total 7325 12399.500000 617539.1500 120162.8300
Center 10
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 384 297.750000 11016.7500 0.0000
U 0 0.000000 0.0000 0.0000
B 5036 4589.250000 201863.2500 0.0000
P 0 0.000000 0.0000 0.0000
D 0 0.000000 0.0000 0.0000
S 99 177.750000 10079.7500 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
4442 13866.750000 739000.4800 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 9961 18931.500000 961960.2300 0.0000
Center 51
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 226 164.000000 5966.2500 0.0000
U 0 0.000000 0.0000 0.0000
B 571 392.500000 15111.0000 0.0000
P 1 4.000000 285.7600 285.7600
D 1 0.750000 27.7500 0.0000
S 0 0.000000 0.0000 0.0000
H 1 0.250000 9.2500 0.0000
T 0 0.000000 0.0000 0.0000
745 1974.500000 118086.4900 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 1545 2536.000000 139486.5000 285.7600
Center 52
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 7 3.500000 142.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 1012 990.250000 48275.2500 83.2500
P 2259 2085.500000 94863.5500 93920.2100
D 4 4.000000 221.4400 0.0000
S 6 7.000000 259.0000 0.0000
H 46 43.750000 2955.0300 0.0000
T 2 2.000000 101.0500 101.0500
676 1437.250000 87591.2300 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 4012 4573.250000 234409.0500 94104.5100
Center 53
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 21 18.500000 739.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 773 715.500000 29755.7500 2.0000
P 2656 2680.500000 125552.7500 125515.7500
D 0 0.000000 0.0000 0.0000
S 17 17.750000 720.5000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
2077 2124.750000 107664.2000 0.0000
Other 2 2.000000 100.0000 0.0000
---------------------------------------------------------
Total 5546 5559.000000 264532.7000 125517.7500
Center 54
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 3 3.000000 150.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 1618 1251.500000 49967.0000 0.0000
P 3677 3184.000000 141169.5000 159531.0000
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
3256 3297.250000 165152.9300 0.0000
Other 3 1.750000 64.7500 0.0000
---------------------------------------------------------
Total 8557 7737.500000 356504.1800 159531.0000
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 0.500000 18.5000 0.0000
P 3275 2663.500000 111179.5000 111179.5000
D 0 0.000000 0.0000 0.0000
S 5 3.500000 168.5000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
4551 4522.243010 268327.9000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 7833 7189.743010 379694.4000 111179.5000
Center 57
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 1 0.500000 18.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 2167 2631.500000 98693.2500 0.0000
P 318 333.250000 20399.7500 20210.5500
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
1540 5272.750000 265969.6500 265941.9000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 4026 8238.000000 385081.1500 286152.4500