CMS/EIP Fiscal Report Statewide
Services beginning 07/01/2016 ending 09/30/2016 Date of Report:10/31/2016 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 12791 38528.00000 1424374.5000 36.9699
Subtotal (Total Children Is Unduplicated) 12791 38528.00000 1424374.5000 36.9699
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 85 130.000000 9750.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 54 74.000000 5550.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 11 15.000000 1125.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 44 76.000000 5700.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 119 179.000000 9906.7500 55.3450
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 978 1489.500000 111610.0200 74.9312
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 470 647.500000 48533.2500 74.9548
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 236 310.000000 23187.5000 74.7984
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 1304 1891.500000 104882.5000 55.4494
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 598 935.000000 70012.5000 74.8797
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 5 5.000000 202.5000 40.5000
MED-99204-OUTPATIENT VISIT, NEW, 45 MINS 1 1.000000 57.2700 57.2700
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 1 1.000000 22.1400 22.1400
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 1 1.000000 51.0500 51.0500
SCREEN-T1023-SCREENING 76 82.000000 4100.0000 50.0000
Subtotal (Total Children Is Unduplicated) 2337 5837.500000 394690.4800 67.6129
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EI Services,Class #03
COUN-H2019HR-INDIVIDUAL/FAMILY THERAPY 18 47.000000 3446.0400 73.3200
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 10 14.750000 368.7500 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 865 4128.750000 206363.5000 49.9821
OCCT-97530-OT SESSION BY LICENSED OT 8 10.750000 767.9800 71.4400
PHY-97110-PT SESSION BY LICENSED PT 10 18.000000 1285.9200 71.4400
PHY-97110HM-PT SESSION BY PT ASST 3 21.000000 1200.3600 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 26 49.500000 3536.2800 71.4400
Subtotal (Total Children Is Unduplicated) 913 4289.750000 216968.8300 50.5784
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Total 48655.250000 2036033.8100 41.8461
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Number of Children (Unduplicated) With at Least One Service 13034
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Center 01
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 46 20.500000 758.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 8067 5400.250000 200337.2700 0.2500
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 8113 5420.750000 201095.7700 0.2500
Center 03
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 219 151.250000 7116.6900 0.0000
P 3901 2506.250000 104487.0000 35805.7500
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 4120 2657.500000 111603.6900 35805.7500
Center 04
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 1 2.000000 74.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 845 1204.000000 48563.0000 0.0000
P 2687 3911.250000 154721.9100 154855.5200
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 3533 5117.250000 203358.9100 154855.5200
Center 05
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 2587 1827.000000 76518.2500 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 2587 1827.000000 76518.2500 0.0000
Center 07
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 7 3.750000 138.7500 0.0000
U 0 0.000000 0.0000 0.0000
B 362 253.250000 9568.7500 0.0000
P 5344 4199.500000 173183.2500 173155.5000
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 5713 4456.500000 182890.7500 173155.5000
Center 09
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 2 4.000000 261.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 235 223.500000 8746.2500 12.5000
P 4610 4555.750000 194699.2700 193359.0000
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 4847 4783.250000 203706.5200 193371.5000
Center 10
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 1345 1092.750000 52386.5000 0.0000
P 4197 3160.250000 142287.7500 142287.7500
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 5542 4253.000000 194674.2500 142287.7500
Center 51
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 1 1.000000 75.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 2926 1815.500000 69836.0000 0.0000
P 1 1.000000 51.0500 51.0500
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 2928 1817.500000 69962.0500 51.0500
Center 52
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 12 21.500000 1555.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 2409 2363.500000 99719.5000 0.0000
P 489 605.750000 36223.0800 35308.8800
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 2910 2990.750000 137498.0800 35308.8800
Center 53
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 3 4.250000 194.2500 0.0000
U 0 0.000000 0.0000 0.0000
B 1849 1760.750000 81803.2900 0.0000
P 2057 1940.000000 86268.7500 86218.7500
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 3909 3705.000000 168266.2900 86218.7500
Center 54
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 2 2.000000 100.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 5484 4547.750000 190091.0000 0.0000
P 748 789.750000 42218.5000 42218.5000
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 6234 5339.500000 232409.5000 42218.5000
Center 55
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 166 131.000000 4847.0000 4070.0000
P 2528 2559.750000 105138.5000 106483.5000
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 2694 2690.750000 109985.5000 110553.5000
Center 57
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 3605 3589.000000 143617.2500 0.0000
P 9 7.500000 447.0000 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 3614 3596.500000 144064.2500 0.0000