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:Program Patients
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 16306 49343.50000 1824304.5000 36.9715
Subtotal (Total Children Is Unduplicated) 16306 49343.50000 1824304.5000 36.9715
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 120 190.000000 14250.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 48 77.000000 5775.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 33 52.000000 3900.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 85 148.500000 11100.0000 74.7475
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 154 236.000000 13098.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 1676 2589.966666 194210.0000 74.9855
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 686 1036.000000 77560.0000 74.8649
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 521 793.500000 59465.0000 74.9401
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 2299 3549.500000 196831.7500 55.4534
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 893 1448.946133 108633.4600 74.9741
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 53 55.000000 2750.0000 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 71 81.000000 4135.0500 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) 3672 10479.41280 703038.0700 67.0875
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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 6420 49436.86000 2471715.3600 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 878 4678.753920 333344.2900 71.2464
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) 7844 62266.95412 3352509.2300 53.8409
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Total 122089.866914 5879851.8000 48.1600
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Number of Children (Unduplicated) With at Least One Service 17736
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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 211 227.500000 13331.6000 0.0000
P 4 3.000000 111.0000 111.0000
D 125 127.500000 6239.0600 0.0000
S 3681 2823.000000 128892.6800 0.0000
H 6068 4236.250000 173847.1300 173847.1300
T 1 0.500000 18.5000 0.0000
29 14.250000 561.6900 0.0000
Other 277 405.000000 26046.0000 0.0000
---------------------------------------------------------
Total 10396 7837.000000 349047.6600 173958.1300
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 2117 1490.500000 66534.0000 0.0000
---------------------------------------------------------
Total 2117 1490.500000 66534.0000 0.0000
Center 03
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 83 57.000000 2109.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 3491 2450.000000 104438.7500 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 3578 2511.000000 106771.7500 27.7500
Center 04
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 527 856.750000 31663.7500 37.0000
U 0 0.000000 0.0000 0.0000
B 828 1123.750000 44970.7500 0.0000
P 3633 5220.000000 206519.0900 201679.9200
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
355 367.250000 22430.7800 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 8349 19439.750000 911895.6400 201716.9200
Center 05
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 15 11.250000 501.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 2395 1571.000000 60621.7500 43378.9900
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
13 9.000000 333.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 2423 1591.250000 61455.7500 43378.9900
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
11040 9572.750000 462335.1600 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 11043 9575.750000 462446.1600 111.0000
Center 07
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 10 10.750000 397.7500 0.0000
U 0 0.000000 0.0000 0.0000
B 2111 1841.250000 78632.4500 129.5000
P 1454 1418.000000 60926.2500 61085.0000
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
176 130.750000 5020.7500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 3756 3406.500000 145302.9500 61214.5000
Center 09
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 2 1.500000 55.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 345 377.000000 15821.2500 0.0000
P 4416 4841.250000 196861.5000 200487.5000
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 5 9.000000 528.7500 637.5000
2491 7775.000000 437843.1700 0.0000
Other 217 368.500000 26789.2500 0.0000
---------------------------------------------------------
Total 7476 13372.250000 677899.4200 201125.0000
Center 10
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 114 81.750000 3024.7500 0.0000
U 0 0.000000 0.0000 0.0000
B 2859 2195.750000 86692.5000 0.0000
P 6748 5808.250000 249372.9700 249187.5000
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 14119 22108.000000 1080376.1900 249187.5000
Center 51
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 5 5.000000 250.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 265 206.250000 10930.0800 0.0000
P 345 256.500000 10868.2500 10867.7500
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
1120 2271.500000 128481.7200 0.0000
Other 1 1.000000 55.5000 0.0000
---------------------------------------------------------
Total 1736 2740.250000 150585.5500 10867.7500
Center 52
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 15 12.750000 743.3900 0.0000
U 0 0.000000 0.0000 0.0000
B 289 301.750000 14234.5800 0.0000
P 1854 1904.750000 88268.9900 88307.0200
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
986 2057.500000 124537.6700 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 3187 4316.500000 230538.0000 88382.0200
Center 53
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 10 9.500000 454.8200 0.0000
U 0 0.000000 0.0000 0.0000
B 2523 2373.360000 112793.7300 336.5000
P 1794 1703.000000 77931.0200 77691.8200
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
1131 1197.750000 65705.9700 0.0000
Other 47 37.000000 1469.1900 0.0000
---------------------------------------------------------
Total 5580 5396.110000 263442.3400 78028.3200
Center 54
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 110 106.000000 4369.7200 0.0000
U 0 0.000000 0.0000 0.0000
B 3252 2814.250000 134625.1800 145.4400
P 3180 2675.750000 118433.3200 117735.5900
D 95 96.000000 6555.7900 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
2582 2688.050000 139579.5900 0.0000
Other 96 75.750000 2871.6300 27.7500
---------------------------------------------------------
Total 9353 8492.800000 409057.0700 117945.7800
Center 55
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 1751 1510.000000 63338.7500 96.2500
P 2913 2457.750000 99682.2500 108155.4800
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
3832 3991.790248 243392.8800 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 8499 7962.956914 406641.6300 108279.4800
Center 57
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 222 266.000000 11344.7500 18.5000
P 3749 4396.250000 177018.7500 173275.0000
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
2129 7187.000000 369494.1900 369494.1900
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 6100 11849.250000 557857.6900 542787.6900