CMS/EIP Fiscal Report Statewide
Services beginning 10/01/2013 ending 12/31/2013 Date of Report:02/18/2014 Page: 1
List order: No List
Payclass Filters:MED
Eligibility Filter:Not Part C
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 408 1531.750000 56674.7500 37.0000
Subtotal (Total Children Is Unduplicated) 408 1531.750000 56674.7500 37.0000
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 11 13.500000 1012.5000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 3 4.500000 337.5000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 0.500000 37.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 3 3.500000 262.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 12 18.000000 999.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 129 186.500000 13987.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 66 95.500000 7162.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 58 69.000000 5175.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 217 301.500000 16733.2500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 141 162.500000 12187.5000 75.0000
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 2 2.000000 101.2600 50.6300
Subtotal (Total Children Is Unduplicated) 320 857.000000 57996.0100 67.6733
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 1 4.000000 200.0000 50.0000
Subtotal (Total Children Is Unduplicated) 1 4.000000 200.0000 50.0000
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Total 2392.750000 114870.7600 48.0078
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Number of Children (Unduplicated) With at Least One Service 418
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Center 02
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 7 3.750000 138.7500 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 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 7 3.750000 138.7500 0.0000
Center 04
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 11 7.000000 525.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 138 246.250000 10008.0000 0.0000
P 166 234.500000 9803.5100 9803.5100
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
74 66.750000 3947.5000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 389 554.500000 24284.0100 9803.5100
Center 09
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 477 773.750000 40692.2500 0.0000
P 6 10.250000 654.0000 654.0000
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 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 483 784.000000 41346.2500 654.0000
Center 10
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 6 6.250000 231.2500 0.0000
U 0 0.000000 0.0000 0.0000
B 705 717.250000 30134.0000 0.0000
P 110 162.500000 10968.7500 10968.7500
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
0 0.000000 0.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 821 886.000000 41334.0000 10968.7500
Center 57
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 2 1.500000 55.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 55 59.500000 2927.2500 0.0000
P 77 99.500000 4585.0000 4585.0000
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
2 4.000000 200.0000 200.0000
Other 0 0.000000 0.0000 0.0000
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Total 136 164.500000 7767.7500 4785.0000