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
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 980 3816.750000 141090.2500 36.9661
Subtotal (Total Children Is Unduplicated) 980 3816.750000 141090.2500 36.9661
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 18 30.000000 2150.0000 71.6667
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 7 11.500000 862.5000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 5 8.500000 637.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 9 14.000000 1050.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 22 38.500000 2136.7500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 301 459.000000 34425.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 125 180.000000 13500.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 106 140.500000 10537.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 382 567.500000 31496.2500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 203 304.500000 22811.0400 74.9131
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 1 1.000000 53.5500 53.5500
SCREEN-T1023-SCREENING 3 3.000000 150.0000 50.0000
Subtotal (Total Children Is Unduplicated) 643 1758.000000 119810.0900 68.1514
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 5 23.000000 1150.0000 50.0000
Subtotal (Total Children Is Unduplicated) 5 23.000000 1150.0000 50.0000
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Total 5597.750000 262050.3400 46.8135
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Number of Children (Unduplicated) With at Least One Service 994
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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 452 372.000000 14238.0000 0.0000
P 0 0.000000 0.0000 0.0000
D 1 1.500000 86.0400 0.0000
S 39 53.750000 3532.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
2 1.000000 37.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 494 428.250000 17893.0400 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 194 175.250000 8163.2500 0.0000
---------------------------------------------------------
Total 194 175.250000 8163.2500 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 86 83.500000 3202.5000 0.0000
P 174 178.750000 8034.7500 6573.2500
D 0 0.000000 0.0000 0.0000
S 1 1.000000 37.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
2 1.500000 55.5000 0.0000
Other 11 7.500000 277.5000 0.0000
---------------------------------------------------------
Total 274 272.250000 11607.2500 6573.2500
Center 04
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 54 68.000000 3185.7500 0.0000
P 178 311.750000 12572.7500 12572.7500
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 3 13.000000 650.0000 0.0000
T 0 0.000000 0.0000 0.0000
44 37.750000 2236.0500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 279 430.500000 18644.5500 12572.7500
Center 05
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 252 228.250000 10136.2500 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 252 228.250000 10136.2500 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
225 222.750000 10429.7500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 225 222.750000 10429.7500 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 0 0.000000 0.0000 0.0000
P 456 501.500000 23942.2500 23942.2500
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 5.000000 259.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 459 506.500000 24201.2500 23942.2500
Center 09
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 9 17.500000 818.5000 0.0000
P 220 321.500000 16046.0000 16046.0000
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
1 1.000000 75.0000 0.0000
Other 41 51.000000 3776.2500 0.0000
---------------------------------------------------------
Total 271 391.000000 20715.7500 16046.0000
Center 10
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 19 15.500000 573.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 431 473.000000 22521.5000 0.0000
P 155 179.500000 9596.7500 9596.7500
D 0 0.000000 0.0000 0.0000
S 9 7.500000 277.5000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
4 6.000000 222.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 618 681.500000 33191.2500 9596.7500
Center 51
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 115 83.250000 3429.5000 0.0000
P 0 0.000000 0.0000 0.0000
D 1 0.750000 27.7500 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
8 8.500000 588.7500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 124 92.500000 4046.0000 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 22 18.750000 921.7500 0.0000
P 259 293.250000 13974.7500 14011.7500
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
18 34.500000 2587.5000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 299 346.500000 17484.0000 14011.7500
Center 53
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 293 308.250000 14113.5000 14113.5000
D 0 0.000000 0.0000 0.0000
S 29 28.750000 1063.7500 1008.2500
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
13 18.500000 1319.2500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 335 355.500000 16496.5000 15121.7500
Center 54
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 394 389.750000 16324.5000 0.0000
P 193 218.750000 10915.0000 10915.0000
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 1 1.000000 37.0000 37.0000
43 68.500000 4079.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 631 678.000000 31355.5000 10952.0000
Center 55
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 367 488.750000 21935.7500 21935.7500
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
54 98.500000 6767.7500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 421 587.250000 28703.5000 21935.7500
Center 57
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 102 133.500000 5430.0000 0.0000
P 48 52.250000 2508.5000 2508.5000
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
10 16.000000 1044.0000 727.5000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 160 201.750000 8982.5000 3236.0000