CMS/EIP Fiscal Report Statewide
Services beginning 01/01/2016 ending 03/31/2016 Date of Report:05/12/2016 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 1097 4008.750000 148240.5000 36.9792
Subtotal (Total Children Is Unduplicated) 1097 4008.750000 148240.5000 36.9792
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 15 27.000000 2025.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 2 3.000000 225.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 7 12.500000 937.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 2 3.000000 225.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 17 28.500000 1526.2500 53.5526
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 324 508.000000 38055.0000 74.9114
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 97 133.500000 10012.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 108 150.500000 11287.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 405 601.000000 33300.0000 55.4077
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 266 440.500000 33000.0000 74.9149
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 1 1.000000 40.5000 40.5000
SCREEN-T1023-SCREENING 2 2.000000 100.0000 50.0000
Subtotal (Total Children Is Unduplicated) 669 1910.500000 130734.2500 68.4293
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 3 7.000000 350.0000 50.0000
Subtotal (Total Children Is Unduplicated) 3 7.000000 350.0000 50.0000
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Total 5926.250000 279324.7500 47.1335
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Number of Children (Unduplicated) With at Least One Service 1123
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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 352 289.250000 10702.2500 0.0000
P 0 0.000000 0.0000 0.0000
D 0 0.000000 0.0000 0.0000
S 16 13.250000 490.2500 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 1 0.500000 18.5000 0.0000
---------------------------------------------------------
Total 369 303.000000 11211.0000 0.0000
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
1 2.000000 111.0000 0.0000
Other 128 123.500000 4902.5000 0.0000
---------------------------------------------------------
Total 129 125.500000 5013.5000 0.0000
Center 03
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 160 144.500000 5864.2500 0.0000
P 341 320.250000 14769.7500 14676.2500
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 501 464.750000 20634.0000 14676.2500
Center 04
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 8 15.000000 688.0000 0.0000
P 188 319.750000 13325.0000 13325.0000
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
19 14.750000 906.7500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 215 349.500000 14919.7500 13325.0000
Center 05
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 99 80.750000 3348.7500 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 99 80.750000 3348.7500 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
198 179.250000 8517.7500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 198 179.250000 8517.7500 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 0 0.000000 0.0000 0.0000
P 521 559.500000 25843.0000 25843.0000
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 7.750000 390.5000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 530 567.250000 26233.5000 25843.0000
Center 09
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 6 9.000000 519.0000 0.0000
P 332 478.250000 25301.5000 25301.5000
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 338 487.250000 25820.5000 25301.5000
Center 10
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 410 457.500000 24124.5000 0.0000
P 184 157.750000 5836.7500 5836.7500
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 594 615.250000 29961.2500 5836.7500
Center 51
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 132 118.750000 4689.7500 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
36 37.000000 2677.5000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 168 155.750000 7367.2500 0.0000
Center 52
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 3 6.000000 450.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 152 189.750000 9958.7500 0.0000
P 66 66.000000 2516.0000 2516.0000
D 9 2.250000 83.2500 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
16 20.000000 1443.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 246 284.000000 14451.0000 2516.0000
Center 53
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 25 21.250000 786.2500 0.0000
U 0 0.000000 0.0000 0.0000
B 199 210.500000 9064.2500 111.0000
P 166 202.500000 9905.0000 9905.0000
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
47 63.500000 3913.5000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 437 497.750000 23669.0000 10016.0000
Center 54
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 443 464.500000 20659.2500 0.0000
P 2 3.000000 195.7500 195.7500
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
83 89.250000 4879.7500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 528 556.750000 25734.7500 195.7500
Center 55
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 656 891.250000 43349.2500 43253.2500
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
42 84.000000 5793.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 698 975.250000 49142.2500 43253.2500
Center 57
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 225 255.750000 11309.2500 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
15 28.500000 1991.2500 1991.2500
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 240 284.250000 13300.5000 1991.2500