CMS/EIP Fiscal Report Statewide
Services beginning 10/01/2015 ending 12/31/2015 Date of Report:02/13/2016 Page: 1
List order: No List
Payclass Filters:MED
Bill Flag Filter:RBPU
Eligibility Filter:All
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 11752 33977.75000 1252214.0000 36.8539
Subtotal (Total Children Is Unduplicated) 11752 33977.75000 1252214.0000 36.8539
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 49 86.500000 6487.5000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 27 45.500000 3412.5000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 11 14.000000 1050.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 34 62.500000 4687.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 73 117.500000 6521.2500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 959 1476.000000 110557.5000 74.9035
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 354 546.500000 40987.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 325 439.000000 32925.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 1215 1840.000000 101999.7500 55.4346
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 695 1041.500000 78112.5000 75.0000
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 9 9.000000 364.5000 40.5000
MED-99204-OUTPATIENT VISIT, NEW, 45 MINS 1 1.000000 57.2700 57.2700
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 2 2.000000 44.2800 22.1400
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 1 1.000000 51.0500 51.0500
SCREEN-T1023-SCREENING 24 24.000000 1200.0000 50.0000
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 1 1.000000 51.0500 51.0500
Subtotal (Total Children Is Unduplicated) 2118 5707.000000 388509.1500 68.0759
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EI Services,Class #03
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 6 6.000000 150.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 679 3275.000000 163625.0000 49.9618
OCCT-97530-OT SESSION BY LICENSED OT 5 9.500000 678.6800 71.4400
PHY-97110-PT SESSION BY LICENSED PT 17 38.000000 2701.7700 71.0992
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 10 29.000000 1701.3300 58.6666
Subtotal (Total Children Is Unduplicated) 712 3357.500000 168856.7800 50.2924
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Total 43042.250000 1809579.9300 42.0419
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Number of Children (Unduplicated) With at Least One Service 11978
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Center 01
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 8 3.000000 118.4400 0.0000
U 0 0.000000 0.0000 0.0000
B 6709 4557.000000 174415.3700 0.0000
P 1 0.250000 9.2500 9.2500
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 0 0.000000 0.0000 0.0000
0 0.000000 0.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 6718 4560.250000 174543.0600 9.2500
Center 03
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 31 12.500000 475.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 181 197.750000 12338.3300 111.0000
P 2691 1675.250000 67705.2500 67785.9920
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 2903 1885.500000 80519.0800 67896.9920
Center 04
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 54 67.000000 2479.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 581 793.750000 30122.7500 0.0000
P 2033 2736.500000 108769.5500 108727.2000
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 2668 3597.250000 141371.3000 108727.2000
Center 05
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 2552 1632.250000 67555.2500 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 2552 1632.250000 67555.2500 0.0000
Center 07
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 28 18.000000 666.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 71 47.250000 1828.0000 0.0000
P 4612 3543.750000 146345.2500 146214.2500
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 0 0.000000 0.0000 0.0000
0 0.000000 0.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 4711 3609.000000 148839.2500 146214.2500
Center 09
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 5 5.000000 198.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 189 225.500000 12554.5000 225.2500
P 4773 4605.000000 198519.5500 309556.8000
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 4967 4835.500000 211272.0500 309782.0500
Center 10
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 270 175.250000 6484.2500 0.0000
U 0 0.000000 0.0000 0.0000
B 6580 5135.750000 228827.0000 0.0000
P 1 0.500000 18.5000 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 6851 5311.500000 235329.7500 0.0000
Center 51
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 14 10.750000 415.2500 0.0000
U 0 0.000000 0.0000 0.0000
B 2583 1681.750000 63177.7500 0.0000
P 1 1.000000 71.4400 71.4400
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 2598 1693.500000 63664.4400 71.4400
Center 52
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 28 52.500000 3918.5000 1050.0000
U 0 0.000000 0.0000 0.0000
B 1826 1802.500000 89044.2500 15060.0000
P 890 741.250000 27388.7500 27386.2500
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 0 0.000000 0.0000 0.0000
0 0.000000 0.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 2744 2596.250000 120351.5000 43496.2500
Center 53
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 1 0.500000 18.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 1845 1741.750000 72330.5000 0.0000
P 1726 1715.250000 80961.5000 81026.2500
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 0 0.000000 0.0000 0.0000
0 0.000000 0.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 3572 3457.500000 153310.5000 81026.2500
Center 54
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 4796 4202.250000 184439.2500 0.0000
P 1 2.000000 74.0000 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 4797 4204.250000 184513.2500 0.0000
Center 55
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 1 1.000000 37.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 171 162.750000 6021.7500 18.5000
P 2126 2077.250000 85484.2500 103345.7500
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 2298 2241.000000 91543.0000 103364.2500
Center 57
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 6 6.750000 249.7500 0.0000
U 0 0.000000 0.0000 0.0000
B 3493 3410.250000 136462.2500 0.0000
P 1 1.500000 55.5000 55.5000
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
0 0.000000 0.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 3500 3418.500000 136767.5000 55.5000