CMS/EIP Fiscal Report Statewide
Services beginning 10/01/2016 ending 12/31/2016 Date of Report:02/04/2017 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 12819 38185.25000 1412127.2500 36.9810
Subtotal (Total Children Is Unduplicated) 12819 38185.25000 1412127.2500 36.9810
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 73 111.000000 8325.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 46 67.500000 5062.5000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 17 19.500000 1462.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 60 90.500000 6787.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 105 159.500000 8852.2500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 966 1477.000000 110737.5000 74.9746
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 419 594.500000 44535.0200 74.9117
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 216 281.500000 21112.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 1209 1736.000000 96023.5200 55.3131
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 548 875.000000 65625.0000 75.0000
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 14 14.000000 567.0000 40.5000
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 1 1.000000 22.1400 22.1400
PSTH-97001-EVAL BY LICENSED PT, INITIAL 1 1.000000 51.0500 51.0500
SCREEN-T1023-SCREENING 66 75.000000 3750.0000 50.0000
SPCH-92524-BEHAV & QUAL ANALYSIS OF
VOICE AND RES 1 1.000000 51.0500 51.0500
Subtotal (Total Children Is Unduplicated) 2183 5504.000000 372964.5300 67.7625
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EI Services,Class #03
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 8 14.000000 350.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 890 4166.250000 208287.5000 49.9940
OCCT-97530-OT SESSION BY LICENSED OT 5 12.000000 857.2800 71.4400
PHY-97110-PT SESSION BY LICENSED PT 5 14.000000 979.7700 69.9836
PHY-97110HM-PT SESSION BY PT ASST 5 22.000000 1257.5200 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 29 81.500000 5784.3600 70.9737
Subtotal (Total Children Is Unduplicated) 928 4309.750000 217516.4300 50.4708
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Total 47999.000000 2002608.2100 41.7219
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Number of Children (Unduplicated) With at Least One Service 13033
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Center 01
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 47 22.250000 823.2500 0.0000
U 0 0.000000 0.0000 0.0000
B 7156 4688.000000 173690.0000 0.0000
P 24 23.500000 1412.4000 1412.4000
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 7227 4733.750000 175925.6500 1412.4000
Center 03
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 131 85.500000 3686.7500 0.0000
P 3149 1984.250000 82946.8000 32646.3000
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 3280 2069.750000 86633.5500 32646.3000
Center 04
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 3 7.500000 277.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 65 102.500000 3792.5000 0.0000
P 3369 4763.750000 189685.8900 190178.4500
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 3437 4873.750000 193755.8900 190178.4500
Center 05
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 2524 1708.000000 70729.7500 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 2524 1708.000000 70729.7500 0.0000
Center 07
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 6 4.750000 175.7500 0.0000
U 0 0.000000 0.0000 0.0000
B 228 154.500000 5868.2500 0.0000
P 5447 4189.250000 172834.7500 172797.7500
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 5681 4348.500000 178878.7500 172797.7500
Center 09
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 117 120.000000 5470.5000 101.7500
P 4057 4152.000000 174454.2300 173984.9800
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 4174 4272.000000 179924.7300 174086.7300
Center 10
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 77 47.250000 1748.2500 0.0000
U 0 0.000000 0.0000 0.0000
B 9325 6685.500000 281593.2500 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 9402 6732.750000 283341.5000 0.0000
Center 51
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 53 36.000000 1332.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 2532 1619.750000 63368.7500 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 2585 1655.750000 64700.7500 0.0000
Center 52
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 9 12.000000 750.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 949 1010.500000 52482.5000 175.7500
P 1791 1566.500000 67865.1400 66646.1200
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 2749 2589.000000 121097.6400 66821.8700
Center 53
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 6 4.250000 157.2500 0.0000
U 0 0.000000 0.0000 0.0000
B 554 535.750000 26091.0000 0.0000
P 2931 2805.000000 125711.0000 125711.0000
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 3491 3345.000000 151959.2500 125711.0000
Center 54
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 3 2.000000 74.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 5199 4305.500000 185784.0000 50.0000
P 721 745.000000 39849.5000 39865.2500
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 5923 5052.500000 225707.5000 39915.2500
Center 55
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 30 25.500000 943.5000 0.0000
P 3240 3084.000000 128563.2500 128563.2500
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 3270 3109.500000 129506.7500 128563.2500
Center 57
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 3 3.000000 111.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 2644 2529.500000 104101.2500 0.0000
P 945 976.250000 36234.2500 35890.0000
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 3592 3508.750000 140446.5000 35890.0000