CMS/EIP Fiscal Report Statewide
Services beginning 01/01/2017 ending 03/31/2017 Date of Report:05/05/2017 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 13669 42747.00000 1580544.2500 36.9744
Subtotal (Total Children Is Unduplicated) 13669 42747.00000 1580544.2500 36.9744
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 88 134.000000 9950.0000 74.2537
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 35 52.000000 3900.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 20 20.500000 1537.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 61 100.000000 7500.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 109 170.500000 9462.7500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 1081 1666.000000 124870.0000 74.9520
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 440 582.500000 43633.2500 74.9069
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 266 355.500000 26662.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 1287 1923.000000 106574.0200 55.4207
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 735 1107.500000 83062.5000 75.0000
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 3 3.000000 121.5000 40.5000
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 1 1.000000 22.1400 22.1400
SCREEN-T1023-SCREENING 78 82.000000 4100.0000 50.0000
Subtotal (Total Children Is Unduplicated) 2478 6197.500000 421396.1600 67.9945
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EI Services,Class #03
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 8 20.000000 500.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 949 4660.250000 233012.5000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 8 15.500000 1107.3200 71.4400
PHY-97110-PT SESSION BY LICENSED PT 17 63.500000 4536.4400 71.4400
PHY-97110HM-PT SESSION BY PT ASST 2 18.000000 1028.8800 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 23 73.000000 5215.1200 71.4400
Subtotal (Total Children Is Unduplicated) 994 4850.250000 245400.2600 50.5954
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Total 53794.750000 2247340.6700 41.7762
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Number of Children (Unduplicated) With at Least One Service 13842
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Center 01
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 86 73.000000 4689.9400 0.0000
U 0 0.000000 0.0000 0.0000
B 8767 5767.750000 220135.5200 0.0000
P 12 14.500000 883.2500 883.2500
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 8865 5855.250000 225708.7100 883.2500
Center 03
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 1069 692.250000 27117.5000 100.0000
P 2329 1520.000000 63376.5000 46551.2750
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 3398 2212.250000 90494.0000 46651.2750
Center 04
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 1 1.000000 55.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 795 998.750000 44354.7500 0.0000
P 3449 5166.500000 203352.1400 203316.6500
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 4245 6166.250000 247762.3900 203316.6500
Center 05
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 1 1.000000 37.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 3086 2137.500000 87294.0000 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 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 3087 2138.500000 87331.0000 0.0000
Center 07
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 2 0.750000 27.7500 0.0000
U 0 0.000000 0.0000 0.0000
B 13 9.250000 342.2500 0.0000
P 5990 4474.500000 184047.2500 184001.0000
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 6005 4484.500000 184417.2500 184001.0000
Center 09
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 2 3.500000 129.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 229 209.250000 8238.2500 27.7500
P 4077 4080.000000 173697.7700 173697.7700
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 4308 4292.750000 182065.5200 173725.5200
Center 10
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 548 383.500000 14189.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 7466 5617.750000 239538.0000 0.0000
P 1864 1403.750000 64433.7500 64433.7500
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 9878 7405.000000 318161.2500 64433.7500
Center 51
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 6 6.500000 278.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 2431 1561.000000 60814.0000 0.0000
P 3 11.000000 785.8400 785.8400
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 2440 1578.500000 61878.3400 785.8400
Center 52
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 287 207.500000 8593.7500 37.0000
P 3105 2840.750000 130718.7100 129795.8800
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 3392 3048.250000 139312.4600 129832.8800
Center 53
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 133 137.250000 6642.2500 0.0000
P 4047 3801.000000 170684.2500 170684.2500
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 4180 3938.250000 177326.5000 170684.2500
Center 54
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 2 1.500000 68.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 4190 3394.250000 140417.5000 0.0000
P 2738 2450.750000 115118.0000 115053.2500
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 6930 5846.500000 255604.0000 115053.2500
Center 55
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 2 3.750000 138.7500 0.0000
P 3970 3632.250000 149682.0000 149682.0000
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 3972 3636.000000 149820.7500 149682.0000
Center 57
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 32 29.750000 1100.7500 0.0000
U 0 0.000000 0.0000 0.0000
B 2388 2322.000000 91389.0000 0.0000
P 866 841.000000 34968.7500 34968.7500
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 3286 3192.750000 127458.5000 34968.7500