CMS/EIP Fiscal Report Statewide
Services beginning 07/01/2019 ending 09/30/2019 Date of Report:11/04/2019 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 15390 45584.00000 1685295.5000 36.9712
Subtotal (Total Children Is Unduplicated) 15390 45584.00000 1685295.5000 36.9712
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 103 162.500000 12187.5000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 37 58.500000 4387.5000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 25 40.000000 3000.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 73 128.000000 9600.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 131 195.000000 10822.5000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 1384 2156.166666 161675.0000 74.9826
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 532 808.000000 60460.0000 74.8267
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 408 627.500000 47015.0000 74.9243
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 1830 2846.000000 157787.5000 55.4418
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 711 1182.446133 88645.9600 74.9683
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 6 6.000000 353.4600 58.9100
MED-99204-OUTPATIENT VISIT, NEW, 45 MINS 1 1.000000 83.2900 83.2900
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 2 2.000000 46.8400 23.4200
OCTF-97168-OT RE-EVAL EST PLAN CARE 14 14.000000 714.7000 51.0500
OCTH-97166-OT EVAL MODERATE COMPLEXITY 14 14.000000 714.7000 51.0500
OCTH-97167-OT EVAL HIGH COMPLEXITY 59 61.000000 3114.0500 51.0500
PSTF-97164-PT RE-EVAL EST PLAN CARE 4 4.000000 204.2000 51.0500
PSTH-97161-PT EVAL LOW COMPLEXITY 3 3.000000 153.1500 51.0500
PSTH-97162-PT EVAL MODERATE COMPLEXITY 20 20.000000 1021.0000 51.0500
PSTH-97163-PT EVAL HIGH COMPLEXITY 71 71.000000 3624.5500 51.0500
SCREEN-T1023-SCREENING 52 53.000000 2650.0000 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 70 80.000000 4084.0000 51.0500
SPCH-92524-BEHAV & QUAL ANALYSIS OF VOICE AND RES 12 12.000000 612.6000 51.0500
SPCH-92610-EVAL OF ORAL,PHARYNGEAL SWALLOWING FUNC 13 13.000000 636.2200 48.9400
Subtotal (Total Children Is Unduplicated) 2997 8559.112799 573644.7700 67.0215
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 2 25.000000 2641.9700 105.6788
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 17 34.750000 868.7500 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 6419 49432.86000 2471515.3600 49.9974
OCCT-97530-OT SESSION BY LICENSED OT 610 2852.250000 203682.2600 71.4111
OCCT-97530HM-OT SESSION BY OT ASST 284 1271.250000 72715.5000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 601 3027.940090 216241.9500 71.4155
PHY-97110HM-PT SESSION BY PT ASST 163 746.400105 42664.2300 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 877 4670.753920 332772.7700 71.2461
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 29 137.250000 7850.7000 57.2000
SPL-92508-GROUP SPL SESSION PER CHILD 31 56.500000 784.2200 13.8800
Subtotal (Total Children Is Unduplicated) 7842 62254.95412 3351737.7100 53.8389
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Total 116398.066914 5610677.9800 48.2025
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Number of Children (Unduplicated) With at Least One Service 16799
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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 197 209.500000 12124.8500 0.0000
P 4 3.000000 111.0000 111.0000
D 125 127.500000 6239.0600 0.0000
S 3536 2676.000000 122028.9300 0.0000
H 5768 3974.250000 162623.6300 162623.6300
T 1 0.500000 18.5000 0.0000
28 14.000000 552.4400 0.0000
Other 242 354.000000 22835.2500 0.0000
---------------------------------------------------------
Total 9901 7358.750000 326533.6600 162734.6300
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 1884 1298.750000 57896.5000 0.0000
---------------------------------------------------------
Total 1884 1298.750000 57896.5000 0.0000
Center 03
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 76 50.750000 1877.7500 0.0000
U 0 0.000000 0.0000 0.0000
B 3194 2153.250000 90841.0000 0.0000
P 2 0.750000 27.7500 27.7500
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
2 3.250000 196.2500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 3274 2208.000000 92942.7500 27.7500
Center 04
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 491 784.750000 28999.7500 37.0000
U 0 0.000000 0.0000 0.0000
B 767 1018.000000 40380.0000 0.0000
P 3391 4835.500000 190076.3400 185031.1700
D 1 1.500000 55.5000 0.0000
S 0 0.000000 0.0000 0.0000
H 3005 11870.500000 606255.7700 0.0000
T 0 0.000000 0.0000 0.0000
322 343.750000 20912.0300 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 7977 18854.000000 886679.3900 185068.1700
Center 05
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 15 11.250000 501.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 2310 1501.750000 57926.5000 41575.2400
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
12 8.250000 305.2500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 2337 1521.250000 58732.7500 41575.2400
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 3 3.000000 111.0000 111.0000
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
10865 9399.000000 453781.6600 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 10868 9402.000000 453892.6600 111.0000
Center 07
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 9 9.750000 360.7500 0.0000
U 0 0.000000 0.0000 0.0000
B 2035 1740.250000 73773.7000 129.5000
P 1393 1331.500000 56822.7500 56981.5000
D 1 0.250000 9.2500 0.0000
S 4 5.500000 316.5000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
166 119.750000 4613.7500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 3608 3207.000000 135896.7000 57111.0000
Center 09
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 2 1.500000 55.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 332 357.000000 14796.2500 0.0000
P 4181 4460.250000 178881.2500 182507.2500
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 3 6.000000 333.0000 450.0000
2488 7769.500000 437469.6700 0.0000
Other 156 266.000000 19296.7500 0.0000
---------------------------------------------------------
Total 7162 12860.250000 650832.4200 182957.2500
Center 10
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 104 74.250000 2747.2500 0.0000
U 0 0.000000 0.0000 0.0000
B 2759 2080.750000 81605.5000 0.0000
P 6424 5414.000000 230351.7200 230166.2500
D 2 2.000000 100.0000 0.0000
S 32 81.000000 4575.2800 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
4364 13939.250000 736610.6900 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 13685 21591.250000 1055990.4400 230166.2500
Center 51
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 5 5.000000 250.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 255 197.000000 10550.8300 0.0000
P 338 246.500000 10386.2500 10385.7500
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
1104 2255.250000 127619.9200 0.0000
Other 1 1.000000 55.5000 0.0000
---------------------------------------------------------
Total 1703 2704.750000 148862.5000 10385.7500
Center 52
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 15 12.750000 743.3900 0.0000
U 0 0.000000 0.0000 0.0000
B 260 259.750000 12169.5800 0.0000
P 1710 1709.500000 79037.2400 78957.8500
D 0 0.000000 0.0000 0.0000
S 5 4.500000 255.5000 75.0000
H 38 35.250000 2497.8700 0.0000
T 0 0.000000 0.0000 0.0000
953 1995.500000 120657.9200 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 2981 4017.250000 215361.5000 79032.8500
Center 53
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 6 6.000000 325.3200 0.0000
U 0 0.000000 0.0000 0.0000
B 2318 2144.110000 102468.7300 186.5000
P 1636 1508.000000 68950.2700 68711.0700
D 32 32.750000 2033.5500 0.0000
S 0 0.000000 0.0000 0.0000
H 43 42.750000 3054.0600 0.0000
T 0 0.000000 0.0000 0.0000
1109 1161.250000 63397.4700 0.0000
Other 34 23.750000 903.9400 0.0000
---------------------------------------------------------
Total 5178 4918.610000 241133.3400 68897.5700
Center 54
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 106 99.250000 4119.9700 0.0000
U 0 0.000000 0.0000 0.0000
B 2939 2487.000000 119424.4300 108.4400
P 2887 2378.750000 105203.8200 104506.0900
D 91 90.500000 6172.5400 0.0000
S 0 0.000000 0.0000 0.0000
H 38 37.000000 2621.8400 37.0000
T 0 0.000000 0.0000 0.0000
2510 2586.500000 133435.3400 0.0000
Other 71 52.750000 2020.6300 27.7500
---------------------------------------------------------
Total 8642 7731.750000 372998.5700 104679.2800
Center 55
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 1575 1314.750000 55126.5000 77.7500
P 2656 2158.750000 86415.2500 89933.6800
D 0 0.000000 0.0000 0.0000
S 2 2.666666 200.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 1 0.750000 27.7500 27.7500
3738 3817.790248 231498.3600 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 7972 7294.706914 373267.8600 90039.1800
Center 57
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 199 237.250000 10062.7500 0.0000
P 3493 4009.500000 160300.0000 156793.4000
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
2128 7183.000000 369294.1900 369294.1900
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 5820 11429.750000 539656.9400 526087.5900