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:Program Patients
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 15100 42443.25000 1568865.2500 36.9638
Subtotal (Total Children Is Unduplicated) 15100 42443.25000 1568865.2500 36.9638
-----------------------------------------------------------------------------------------------------------------------
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 133 214.000000 16050.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 71 105.000000 7875.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 18 32.000000 2400.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 64 96.500000 7237.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 151 242.000000 13431.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 1652 2641.500000 198112.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 807 1270.000000 95250.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 358 607.000000 45525.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 2193 3427.000000 190082.0000 55.4660
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 960 1516.500000 113700.0000 74.9753
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 21 21.000000 1237.1100 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 49 50.000000 2500.0000 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) 3430 10401.50000 702366.6700 67.5255
-----------------------------------------------------------------------------------------------------------------------
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 6728 50733.00000 2535354.6400 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) 7659 60544.49301 3208202.0400 52.9892
-----------------------------------------------------------------------------------------------------------------------
Total 113389.243010 5479433.9600 48.3241
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 16946
-----------------------------------------------------------------------------------------------------------------------
Center 01
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 616 441.250000 18223.0900 0.0000
U 0 0.000000 0.0000 0.0000
B 744 823.000000 50248.6200 0.0000
P 6372 4131.500000 154549.8300 151640.2800
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
9 2.750000 101.7500 0.0000
Other 406 541.000000 32579.7000 0.0000
---------------------------------------------------------
Total 8281 6074.750000 262514.7000 151677.2800
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 1655 1233.000000 55601.2500 0.0000
---------------------------------------------------------
Total 1655 1233.000000 55601.2500 0.0000
Center 03
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 97 72.500000 3254.2500 0.0000
U 0 0.000000 0.0000 0.0000
B 3072 2366.250000 104534.7500 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
34 58.500000 4040.7500 0.0000
Other 1 0.500000 18.5000 0.0000
---------------------------------------------------------
Total 3206 2499.500000 111913.0000 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 1207 1769.000000 68749.0000 0.0000
P 2815 4449.500000 176268.8800 173571.3900
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
456 637.000000 41141.0400 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 7028 17668.500000 836307.1200 173571.3900
Center 05
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 65 46.250000 1711.2500 0.0000
U 0 0.000000 0.0000 0.0000
B 2272 1531.500000 60339.2500 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 2340 1581.000000 62265.7500 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
11883 10276.750000 493325.8900 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 11883 10276.750000 493325.8900 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 41 36.500000 1439.5000 0.0000
P 3838 3385.250000 144593.8900 144529.1400
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
35 24.000000 982.5000 0.0000
Other 2 1.000000 37.0000 0.0000
---------------------------------------------------------
Total 3937 3464.250000 147804.3900 144529.1400
Center 09
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 202 241.250000 8926.2500 0.0000
U 0 0.000000 0.0000 0.0000
B 1776 1734.250000 68773.0000 124.5000
P 3023 3148.000000 131004.7500 130894.8900
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
2393 7398.500000 407574.4000 0.0000
Other 225 367.500000 26959.0000 0.0000
---------------------------------------------------------
Total 7619 12889.500000 643237.4000 131019.3900
Center 10
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 402 317.000000 11729.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 5337 4969.000000 220869.7500 0.0000
P 0 0.000000 0.0000 0.0000
D 0 0.000000 0.0000 0.0000
S 109 198.500000 11280.5000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
4445 13871.250000 739298.9800 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 10293 19355.750000 983178.2300 0.0000
Center 51
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 230 165.750000 6031.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 626 441.000000 17109.0000 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
772 2001.750000 120043.7400 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 1631 2613.500000 143506.5000 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 1090 1102.500000 54661.5000 83.2500
P 2448 2307.750000 104302.3000 103358.9600
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
706 1495.750000 91705.7300 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 4309 4966.250000 254348.5500 103543.2600
Center 53
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 21 18.500000 739.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 837 789.000000 32932.5000 29.7500
P 2858 2922.500000 136970.5000 136933.5000
D 0 0.000000 0.0000 0.0000
S 19 19.250000 776.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
2121 2180.250000 110744.7000 0.0000
Other 2 2.000000 100.0000 0.0000
---------------------------------------------------------
Total 5858 5931.500000 282263.2000 136963.2500
Center 54
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 3 3.000000 150.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 1801 1436.500000 57609.5000 0.0000
P 3997 3525.000000 156606.5000 174968.0000
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
3371 3448.000000 173493.9300 0.0000
Other 5 4.250000 157.2500 0.0000
---------------------------------------------------------
Total 9177 8416.750000 388017.1800 174968.0000
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 3753 3206.500000 135943.5000 135943.5000
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
4656 4732.243010 283219.9000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 8416 7942.743010 419350.4000 135943.5000
Center 57
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 1 0.500000 18.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 2298 2819.500000 106232.2500 0.0000
P 365 381.750000 23505.0000 23315.8000
D 1 1.000000 75.0000 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 4205 8475.500000 395800.4000 289257.7000