CMS/EIP Fiscal Report Statewide
Services beginning 04/01/2017 ending 06/30/2017 Date of Report:08/05/2017 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 13566 42241.00000 1562162.5000 36.9821
Subtotal (Total Children Is Unduplicated) 13566 42241.00000 1562162.5000 36.9821
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 78 125.500000 9412.5000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 49 81.500000 6112.5000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 9 11.000000 825.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 67 106.000000 7950.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 100 153.000000 8491.5000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 1021 1532.000000 114875.0000 74.9837
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 411 575.500000 43162.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 208 293.000000 21975.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 1335 2015.000000 111804.7500 55.4862
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 767 1144.000000 85762.5000 74.9672
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 4 4.000000 214.2000 53.5500
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 1 1.000000 26.6100 26.6100
SCREEN-T1023-SCREENING 68 68.000000 3400.0000 50.0000
Subtotal (Total Children Is Unduplicated) 2488 6109.500000 414012.0600 67.7653
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 1 1.000000 782.0400 782.0400
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 9 28.000000 700.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 862 3612.750000 180637.5000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 13 34.250000 2446.8200 71.4400
PHY-97110-PT SESSION BY LICENSED PT 25 47.000000 3357.6800 71.4400
PHY-97110HM-PT SESSION BY PT ASST 2 9.000000 514.4400 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 15 29.500000 2107.4800 71.4400
Subtotal (Total Children Is Unduplicated) 915 3761.500000 190545.9600 50.6569
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Total 52112.000000 2166720.5200 41.5781
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Number of Children (Unduplicated) With at Least One Service 13785
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Center 01
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 89 79.750000 3570.6700 0.0000
U 0 0.000000 0.0000 0.0000
B 8539 5851.750000 232075.5500 0.0000
P 17 17.000000 1860.7600 1860.7600
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 8645 5948.500000 237506.9800 1860.7600
Center 03
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 1608 1002.000000 38357.7500 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 1608 1002.000000 38357.7500 0.0000
Center 04
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 1 2.750000 101.7500 0.0000
U 0 0.000000 0.0000 0.0000
B 3212 4946.750000 186561.0000 0.0000
P 1276 1681.750000 73756.3100 73773.8800
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 4489 6631.250000 260419.0600 73773.8800
Center 05
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 10 6.000000 222.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 2816 1909.500000 76661.0000 0.0000
P 1 1.000000 25.0000 25.0000
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 2827 1916.500000 76908.0000 25.0000
Center 07
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 24 20.250000 749.2500 0.0000
P 5833 4612.250000 190779.0000 190769.7500
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 5857 4632.500000 191528.2500 190769.7500
Center 09
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 2 3.000000 225.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 61 69.750000 3655.5000 0.0000
P 4538 4630.250000 190671.2500 193243.3190
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 4601 4703.000000 194551.7500 193243.3190
Center 10
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 10 4.500000 166.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 10518 8246.000000 347868.0000 0.0000
P 1 0.250000 9.2500 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 10529 8250.750000 348043.7500 0.0000
Center 51
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 2478 1558.500000 61166.5000 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 2478 1558.500000 61166.5000 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 392 423.500000 21400.7500 142.5000
P 3126 2816.250000 129149.4800 128919.0000
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 3518 3239.750000 150550.2300 129061.5000
Center 53
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 3 1.500000 55.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 460 384.500000 16606.5000 1470.7500
P 4136 4012.250000 181204.2500 181148.7500
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 4599 4398.250000 197866.2500 182619.5000
Center 54
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 3199 2674.250000 116457.7500 0.0000
P 30 29.000000 1505.5000 1487.0000
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 3229 2703.250000 117963.2500 1487.0000
Center 55
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 4 6.000000 374.0000 0.0000
P 4068 3682.750000 151195.2500 151084.4300
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 4072 3688.750000 151569.2500 151084.4300
Center 57
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 2 3.000000 111.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 1329 1305.500000 50366.2500 0.0000
P 2127 2082.750000 88045.5000 88045.5000
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 3458 3391.250000 138522.7500 88045.5000