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
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 866 3299.250000 121832.7500 36.9274
Subtotal (Total Children Is Unduplicated) 866 3299.250000 121832.7500 36.9274
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 9 17.000000 1275.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 12 17.500000 1312.5000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 1.000000 75.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 12 18.500000 1387.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 19 33.000000 1831.5000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 267 397.500000 29812.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 143 192.000000 14370.7500 74.8477
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 90 137.500000 10312.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 367 536.500000 29748.0000 55.4483
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 192 294.500000 22087.5000 75.0000
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 7 7.000000 283.5000 40.5000
SCREEN-T1023-SCREENING 7 8.000000 400.0000 50.0000
Subtotal (Total Children Is Unduplicated) 598 1660.000000 112896.2500 68.0098
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 1 6.000000 300.0000 50.0000
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 1 1.000000 71.4400 71.4400
Subtotal (Total Children Is Unduplicated) 2 7.000000 371.4400 53.0629
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Total 4966.250000 235100.4400 47.3396
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Number of Children (Unduplicated) With at Least One Service 901
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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 319 252.250000 9390.2500 0.0000
P 0 0.000000 0.0000 0.0000
D 0 0.000000 0.0000 0.0000
S 50 51.500000 2645.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
11 13.750000 827.7500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 380 317.500000 12863.0000 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
0 0.000000 0.0000 0.0000
Other 144 133.000000 5078.2500 0.0000
---------------------------------------------------------
Total 144 133.000000 5078.2500 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 18 17.750000 922.7500 0.0000
P 283 253.500000 11416.5000 5228.2500
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
1 1.000000 55.5000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 302 272.250000 12394.7500 5228.2500
Center 04
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 26 36.000000 1727.5000 0.0000
P 166 304.500000 12737.7500 12821.2800
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
44 49.500000 2532.7500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 236 390.000000 16998.0000 12821.2800
Center 05
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 235 228.750000 10078.7500 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 235 228.750000 10078.7500 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
128 127.250000 6028.2500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 128 127.250000 6028.2500 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 3 2.250000 83.2500 0.0000
P 489 562.500000 26282.0000 26282.0000
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 492 564.750000 26365.2500 26282.0000
Center 09
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 2 4.000000 261.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 4 5.000000 185.0000 0.0000
P 278 406.750000 20288.0000 19772.7500
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
36 48.500000 3637.5000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 320 464.250000 24371.5000 19772.7500
Center 10
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 108 127.000000 6718.0000 0.0000
P 288 325.750000 16841.5000 16841.5000
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 396 452.750000 23559.5000 16841.5000
Center 51
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 76 53.250000 2110.0000 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
14 14.500000 1048.5000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 90 67.750000 3158.5000 0.0000
Center 52
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 2 4.000000 300.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 179 214.750000 8896.0000 0.0000
P 42 80.500000 5286.7500 5286.7500
D 0 0.000000 0.0000 0.0000
S 3 6.000000 450.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
14 26.500000 1837.5000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 240 331.750000 16770.2500 5286.7500
Center 53
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 1 2.000000 111.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 64 69.250000 3431.7500 0.0000
P 152 183.750000 8602.5000 8602.5000
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 1 1.000000 37.0000 0.0000
58 69.500000 3352.7500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 276 325.500000 15535.0000 8602.5000
Center 54
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 414 436.250000 18492.0000 0.0000
P 28 40.000000 2795.2500 2795.2500
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
31 42.500000 3041.2500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 473 518.750000 24328.5000 2795.2500
Center 55
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 20 18.250000 675.2500 573.5000
P 294 410.750000 18371.2500 18371.2500
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
62 123.000000 8480.4400 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 376 552.000000 27526.9400 18944.7500
Center 57
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 158 203.000000 8925.0000 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
10 17.000000 1119.0000 988.5000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 168 220.000000 10044.0000 988.5000