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
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 1031 3411.500000 125633.5000 36.8265
Subtotal (Total Children Is Unduplicated) 1031 3411.500000 125633.5000 36.8265
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 7 12.500000 937.5000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 5 5.500000 412.5000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 3 3.500000 262.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 2 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 272 411.500000 30862.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 102 146.000000 10950.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 108 160.000000 12000.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 371 558.000000 30885.7500 55.3508
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 235 353.000000 26475.0000 75.0000
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 3 3.000000 121.5000 40.5000
SCREEN-T1023-SCREENING 5 5.000000 250.0000 50.0000
Subtotal (Total Children Is Unduplicated) 603 1679.500000 114418.7500 68.1267
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 3 18.000000 900.0000 50.0000
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 1 1.000000 71.4400 71.4400
Subtotal (Total Children Is Unduplicated) 4 19.000000 971.4400 51.1284
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Total 5110.000000 241023.6900 47.1671
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Number of Children (Unduplicated) With at Least One Service 1067
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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 298 236.250000 8937.7500 0.0000
P 1 0.250000 9.2500 9.2500
D 0 0.000000 0.0000 0.0000
S 7 4.750000 289.7500 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
5 2.500000 92.5000 0.0000
Other 4 4.500000 249.7500 0.0000
---------------------------------------------------------
Total 315 248.250000 9579.0000 9.2500
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
9 17.000000 1236.0000 0.0000
Other 72 72.000000 2830.5000 0.0000
---------------------------------------------------------
Total 81 89.000000 4066.5000 0.0000
Center 03
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 1 0.750000 27.7500 0.0000
U 0 0.000000 0.0000 0.0000
B 41 53.750000 3745.0000 37.0000
P 315 280.500000 12123.5000 12048.0000
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
15 5.000000 185.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 372 340.000000 16081.2500 12085.0000
Center 04
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 1 0.250000 9.2500 0.0000
U 0 0.000000 0.0000 0.0000
B 24 47.000000 1776.5000 0.0000
P 96 145.000000 6201.7500 6201.7500
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
49 40.500000 2354.5000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 170 232.750000 10342.0000 6201.7500
Center 05
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 163 144.250000 6553.2500 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 163 144.250000 6553.2500 0.0000
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
165 128.750000 6066.2500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 165 128.750000 6066.2500 0.0000
Center 07
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 1 1.500000 55.5000 0.0000
P 423 456.250000 21144.7500 21144.7500
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 424 457.750000 21200.2500 21144.7500
Center 09
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 28 40.750000 2588.2500 0.0000
P 343 524.000000 26807.2500 26844.7500
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 371 564.750000 29395.5000 26844.7500
Center 10
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 10 8.500000 314.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 598 622.250000 30798.5000 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
4 14.250000 670.2500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 612 645.000000 31783.2500 0.0000
Center 51
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 97 73.000000 2747.2500 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
11 11.500000 843.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 108 84.500000 3590.2500 0.0000
Center 52
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 6 12.000000 900.0000 220.0000
U 0 0.000000 0.0000 0.0000
B 179 222.500000 10952.5000 1677.5000
P 107 101.750000 3764.7500 3764.7500
D 0 0.000000 0.0000 0.0000
S 1 2.000000 150.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
13 25.000000 1875.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 306 363.250000 17642.2500 5662.2500
Center 53
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 149 166.750000 7144.5000 0.0000
P 151 162.250000 7658.5000 7658.5000
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
81 103.000000 5191.7500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 381 432.000000 19994.7500 7658.5000
Center 54
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 396 413.500000 18860.5000 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
82 90.750000 4727.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 478 504.250000 23587.5000 0.0000
Center 55
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 22 28.000000 1036.0000 0.0000
P 420 522.750000 23027.7500 23018.0000
D 0 0.000000 0.0000 0.0000
S 23 12.000000 444.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
59 115.000000 7704.9400 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 524 677.750000 32212.6900 23018.0000
Center 57
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 170 177.750000 7624.0000 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
12 20.000000 1305.0000 1344.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 182 197.750000 8929.0000 1344.0000