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
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 930 3617.000000 133626.5000 36.9440
Subtotal (Total Children Is Unduplicated) 930 3617.000000 133626.5000 36.9440
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 14 25.000000 1875.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 10 16.500000 1237.5000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 7 12.000000 900.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 15 25.500000 1912.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 26 42.000000 2331.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 347 524.500000 39337.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 130 186.500000 13987.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 95 139.500000 10462.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 403 595.500000 32967.0000 55.3602
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 162 246.500000 18487.5000 75.0000
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 3 3.000000 121.5000 40.5000
SCREEN-T1023-SCREENING 7 7.000000 350.0000 50.0000
Subtotal (Total Children Is Unduplicated) 654 1823.500000 123969.5000 67.9844
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 4 16.000000 800.0000 50.0000
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 1 5.000000 357.2000 71.4400
Subtotal (Total Children Is Unduplicated) 5 21.000000 1157.2000 55.1048
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Total 5461.500000 258753.2000 47.3777
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Number of Children (Unduplicated) With at Least One Service 947
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Center 01
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 3 1.500000 55.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 362 282.000000 10455.0000 0.0000
P 0 0.000000 0.0000 0.0000
D 25 38.000000 2440.5000 0.0000
S 80 95.250000 4740.7500 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
4 3.500000 148.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 474 420.250000 17839.7500 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 177 151.500000 6611.2500 0.0000
---------------------------------------------------------
Total 177 151.500000 6611.2500 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 2 2.250000 83.2500 0.0000
P 270 259.250000 12266.7500 6884.2500
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 5 6.000000 222.0000 0.0000
---------------------------------------------------------
Total 277 267.500000 12572.0000 6884.2500
Center 04
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 3 7.750000 286.7500 0.0000
P 237 404.500000 17490.2500 17593.3700
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 2 3.000000 150.0000 0.0000
T 0 0.000000 0.0000 0.0000
21 19.500000 1253.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 263 434.750000 19180.0000 17593.3700
Center 05
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 178 159.500000 7497.5000 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
0 0.000000 0.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 178 159.500000 7497.5000 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
178 193.750000 9148.2500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 178 193.750000 9148.2500 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 15 13.000000 481.0000 0.0000
P 555 594.500000 27846.2500 27846.2500
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
3 3.000000 187.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 573 610.500000 28514.2500 27846.2500
Center 09
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 11 17.750000 770.7500 0.0000
P 237 358.500000 17253.5000 17253.5000
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
1 2.000000 150.0000 0.0000
Other 40 55.000000 4125.0000 0.0000
---------------------------------------------------------
Total 289 433.250000 22299.2500 17253.5000
Center 10
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 4 3.250000 120.2500 0.0000
U 0 0.000000 0.0000 0.0000
B 611 650.500000 30530.2500 0.0000
P 0 0.000000 0.0000 0.0000
D 0 0.000000 0.0000 0.0000
S 14 13.000000 481.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
1 2.000000 74.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 630 668.750000 31205.5000 0.0000
Center 51
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 3 3.250000 120.2500 0.0000
U 0 0.000000 0.0000 0.0000
B 128 105.500000 4314.0000 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
23 25.500000 1873.5000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 154 134.250000 6307.7500 0.0000
Center 52
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 56 98.000000 6167.7500 0.0000
P 168 194.500000 8198.2500 8198.2500
D 0 0.000000 0.0000 0.0000
S 2 4.000000 300.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
11 20.500000 1537.5000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 237 317.000000 16203.5000 8198.2500
Center 53
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 4 6.000000 391.5000 0.0000
P 117 144.500000 6572.5000 6572.5000
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
35 43.250000 2043.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 156 193.750000 9007.0000 6572.5000
Center 54
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 487 490.500000 21800.5000 0.0000
P 49 62.250000 4090.7500 4090.7500
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
83 102.000000 5573.2500 4080.5000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 619 654.750000 31464.5000 8171.2500
Center 55
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 9 10.500000 388.5000 0.0000
P 379 504.000000 23436.0000 23436.0000
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
74 132.000000 8983.2000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 462 646.500000 32807.7000 23436.0000
Center 57
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 94 119.000000 5722.0000 0.0000
P 31 46.500000 1720.5000 1720.5000
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
6 10.000000 652.5000 522.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 131 175.500000 8095.0000 2242.5000