CMS/EIP Fiscal Report Statewide
Services beginning 01/01/2019 ending 03/31/2019 Date of Report:05/04/2019 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 16251 46877.61875 1733391.6444 36.9770
Subtotal (Total Children Is Unduplicated) 16251 46877.61875 1733391.6444 36.9770
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Screening, Eval, and Assessment,Class #02
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 1 1.000000 13.8700 13.8700
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 1 1.000000 27.8300 27.8300
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 116 195.800000 14623.1500 74.6841
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 47 79.500000 5722.5000 71.9811
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 23 39.500000 2962.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 64 102.000000 7650.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 141 230.500000 12792.7500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 1741 2729.700000 204605.2500 74.9552
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 812 1286.000000 96292.5000 74.8775
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 350 581.500000 43573.5000 74.9329
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 2285 3502.500000 194222.2500 55.4525
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 820 1327.800000 99412.5000 74.8701
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 26 26.000000 1531.6600 58.9100
MED-99204-OUTPATIENT VISIT, NEW, 45 MINS 5 5.000000 416.4500 83.2900
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 7 7.000000 163.9400 23.4200
OCTF-97168-OT RE-EVAL EST PLAN CARE 15 15.000000 765.7500 51.0500
OCTH-97166-OT EVAL MODERATE COMPLEXITY 22 22.000000 1123.1000 51.0500
OCTH-97167-OT EVAL HIGH COMPLEXITY 46 46.000000 2348.3000 51.0500
PSTF-97164-PT RE-EVAL EST PLAN CARE 9 9.000000 459.4500 51.0500
PSTH-97161-PT EVAL LOW COMPLEXITY 2 2.000000 102.1000 51.0500
PSTH-97162-PT EVAL MODERATE COMPLEXITY 10 10.000000 510.5000 51.0500
PSTH-97163-PT EVAL HIGH COMPLEXITY 50 50.000000 2552.5000 51.0500
SCREEN-T1023-SCREENING 73 76.000000 3800.0000 50.0000
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 51 51.000000 2603.5500 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 3 3.000000 146.8200 48.9400
Subtotal (Total Children Is Unduplicated) 3517 10402.80000 698626.9200 67.1576
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 1 1.000000 75.0800 75.0800
COUN-H2019HR-INDIVIDUAL/FAMILY THERAPY 5 15.000000 1099.8000 73.3200
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 17 37.750000 943.7500 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 6147 45335.65000 2266163.8800 49.9864
OCCT-97530-OT SESSION BY LICENSED OT 538 2575.000000 183587.2800 71.2960
OCCT-97530HM-OT SESSION BY OT ASST 258 1196.749473 68454.0700 57.2000
PHY-97110-PT SESSION BY LICENSED PT 586 3082.000000 219681.9200 71.2790
PHY-97110HM-PT SESSION BY PT ASST 140 770.000000 44013.2000 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 822 4475.750000 318392.0300 71.1371
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 17 56.000000 3203.2000 57.2000
SPL-92508-GROUP SPL SESSION PER CHILD 15 38.500000 534.3800 13.8800
Subtotal (Total Children Is Unduplicated) 7450 57583.39947 3106148.5900 53.9417
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Total 114863.818223 5538167.1544 48.2151
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Number of Children (Unduplicated) With at Least One Service 17780
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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 656 429.250000 18310.2300 0.0000
P 63 45.500000 1865.5500 1522.3000
D 51 50.500000 2662.0200 0.0000
S 176 175.250000 10071.7600 0.0000
H 8342 5823.000000 243299.3800 208951.7500
T 2 0.500000 18.5000 0.0000
29 19.250000 788.2500 0.0000
Other 236 365.000000 23138.0000 138.7500
---------------------------------------------------------
Total 9555 6908.250000 300153.6900 210612.8000
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 2291 1532.000000 66837.5000 0.0000
---------------------------------------------------------
Total 2291 1532.000000 66837.5000 0.0000
Center 03
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 52 29.750000 1100.7500 0.0000
U 0 0.000000 0.0000 0.0000
B 3968 2815.500000 121118.7500 0.0000
P 148 147.500000 6837.2500 6837.2500
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 1 0.250000 9.2500 0.0000
67 65.000000 4517.8900 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 4236 3058.000000 133583.8900 6837.2500
Center 04
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 67 83.250000 3080.2500 0.0000
U 0 0.000000 0.0000 0.0000
B 2120 3046.500000 119318.5800 0.0000
P 752 1146.250000 46156.6500 42464.9000
D 0 0.000000 0.0000 0.0000
S 2 5.000000 185.0000 0.0000
H 2293 9260.500000 472781.1300 0.0000
T 0 0.000000 0.0000 0.0000
1788 2525.750000 114100.6900 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 7022 16067.250000 755622.3000 42464.9000
Center 05
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 42 50.500000 3242.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 2476 1641.750000 62438.2500 0.0000
P 2 4.000000 100.0000 150.0000
D 10 3.500000 129.5000 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
12 8.750000 336.7500 0.0000
Other 1 1.000000 37.0000 0.0000
---------------------------------------------------------
Total 2543 1709.500000 66284.0000 150.0000
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
11813 9841.500000 471916.7700 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 11813 9841.500000 471916.7700 0.0000
Center 07
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 6 3.000000 111.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 1568 1354.250000 56144.8000 55.5000
P 2732 2564.000000 110611.7500 109841.5000
D 1 0.500000 18.5000 0.0000
S 104 75.500000 2808.5000 0.0000
H 1 1.000000 37.0000 37.0000
T 0 0.000000 0.0000 0.0000
72 64.250000 2870.2500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 4484 4062.500000 172601.8000 109934.0000
Center 09
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 16 13.500000 632.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 347 348.000000 17142.5000 1683.2500
P 4829 4883.750000 194222.5000 207799.1700
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
2413 7462.000000 424391.7700 142348.8400
Other 180 295.000000 21462.0000 0.0000
---------------------------------------------------------
Total 7785 13002.250000 657851.2700 351831.2600
Center 10
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 208 144.000000 5328.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 2000 1529.750000 60098.5000 46.2500
P 4078 3705.750000 165190.3900 161151.0300
D 316 314.500000 16064.8200 0.0000
S 1437 1372.000000 60395.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
4301 13361.000000 715278.7800 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 12340 20427.000000 1022355.4900 161197.2800
Center 51
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 2 1.500000 74.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 1091 803.250000 30926.3200 0.0000
P 2 10.250000 607.8800 0.0000
D 11 8.000000 296.0000 0.0000
S 1 0.250000 9.2500 0.0000
H 1 0.500000 18.5000 0.0000
T 0 0.000000 0.0000 0.0000
546 1584.750000 94100.1600 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 1654 2408.500000 126032.1100 0.0000
Center 52
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 5 3.000000 143.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 1339 1239.750000 56386.7300 0.0000
P 1563 1504.500000 71300.8300 70954.2000
D 21 18.750000 762.6300 0.0000
S 5 2.500000 92.5000 0.0000
H 183 191.250000 9796.3900 533.3500
T 5 7.750000 510.7800 0.0000
1019 1956.250000 118140.0500 0.0000
Other 2 3.000000 111.0000 55.5000
---------------------------------------------------------
Total 4142 4926.750000 257244.4100 71543.0500
Center 53
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 7 8.250000 381.2500 0.0000
U 0 0.000000 0.0000 0.0000
B 1344 1283.000000 59727.9900 118.5000
P 1809 1679.750000 77186.8700 75841.6300
D 22 16.250000 857.2700 0.0000
S 63 53.750000 1942.5000 1850.0000
H 2 1.500000 107.1600 0.0000
T 0 0.000000 0.0000 0.0000
1975 2006.250000 105879.9000 0.0000
Other 4 2.750000 170.6300 0.0000
---------------------------------------------------------
Total 5226 5051.500000 246253.5700 77810.1300
Center 54
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 10 8.750000 397.1900 0.0000
U 0 0.000000 0.0000 0.0000
B 2272 1945.750000 90886.5400 68.5000
P 2988 2399.500000 103762.1700 103252.5600
D 46 36.000000 1646.3500 0.0000
S 185 103.750000 3820.2500 3820.2500
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
3820 3834.750000 192236.8000 0.0000
Other 19 18.250000 927.6300 0.0000
---------------------------------------------------------
Total 9340 8346.750000 393676.9300 107141.3100
Center 55
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 2329 2123.275135 90330.1800 150.0000
P 1548 1276.043615 53195.4644 53068.9500
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
4165 4297.249473 263175.0300 0.0000
Other 3 5.000000 185.0000 185.0000
---------------------------------------------------------
Total 8045 7701.568223 406885.6744 53403.9500
Center 57
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 1151 1476.750000 59536.7500 166.5000
P 2141 2604.000000 107735.5000 106002.8500
D 1 1.000000 75.0000 75.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
1683 5738.250000 293502.0000 293502.0000
Other 1 0.500000 18.5000 0.0000
---------------------------------------------------------
Total 4977 9820.500000 460867.7500 399746.3500