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
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 1078 4176.750000 154456.5000 36.9801
Subtotal (Total Children Is Unduplicated) 1078 4176.750000 154456.5000 36.9801
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 15 25.500000 1912.5000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 8 11.500000 862.5000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 3 5.500000 412.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 9 18.500000 1387.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 25 39.500000 2192.2500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 306 458.500000 34362.5000 74.9455
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 142 201.500000 15112.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 119 165.500000 12412.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 420 629.000000 34826.2500 55.3676
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 227 343.500000 25762.5000 75.0000
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 4 4.000000 214.2000 53.5500
SCREEN-T1023-SCREENING 6 6.000000 300.0000 50.0000
Subtotal (Total Children Is Unduplicated) 678 1908.500000 129757.7000 67.9894
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 3 16.000000 800.0000 50.0000
Subtotal (Total Children Is Unduplicated) 3 16.000000 800.0000 50.0000
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Total 6101.250000 285014.2000 46.7141
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Number of Children (Unduplicated) With at Least One Service 1092
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Center 01
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 2 2.250000 83.2500 0.0000
U 0 0.000000 0.0000 0.0000
B 344 286.750000 11914.7500 0.0000
P 0 0.000000 0.0000 0.0000
D 0 0.000000 0.0000 0.0000
S 8 11.000000 407.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 1 0.500000 18.5000 0.0000
1 1.500000 55.5000 0.0000
Other 10 15.000000 1027.5000 0.0000
---------------------------------------------------------
Total 366 317.000000 13506.5000 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 117 99.000000 4332.7500 0.0000
---------------------------------------------------------
Total 117 99.000000 4332.7500 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 165 145.000000 5365.0000 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
136 118.750000 4393.7500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 301 263.750000 9758.7500 0.0000
Center 04
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 162 347.250000 13413.2500 0.0000
P 122 192.500000 8829.2500 8829.2500
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
52 46.750000 2974.7000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 336 586.500000 25217.2000 8829.2500
Center 05
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 218 203.250000 8812.2500 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 218 203.250000 8812.2500 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
280 286.000000 13429.5000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 280 286.000000 13429.5000 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 2 2.000000 74.0000 0.0000
P 477 531.750000 24843.2500 24843.2500
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
7 9.750000 606.7500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 486 543.500000 25524.0000 24843.2500
Center 09
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 7 10.750000 662.7500 0.0000
P 253 382.750000 17484.2500 17483.7500
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
3 3.500000 262.5000 0.0000
Other 71 96.500000 7188.7500 0.0000
---------------------------------------------------------
Total 334 493.500000 25598.2500 17483.7500
Center 10
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 486 513.250000 24260.7500 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
4 6.250000 231.2500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 490 519.500000 24492.0000 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 132 98.000000 3985.7500 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
6 6.000000 430.5000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 138 104.000000 4416.2500 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 39 62.000000 3505.5000 27.7500
P 224 278.250000 13293.5000 13293.5000
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
15 23.000000 1706.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 278 363.250000 18505.0000 13321.2500
Center 53
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 2 1.000000 37.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 33 37.000000 1989.0000 83.2500
P 271 319.000000 14699.2500 14699.2500
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
37 43.750000 2641.2500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 343 400.750000 19366.5000 14782.5000
Center 54
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 353 388.500000 17709.7500 0.0000
P 4 5.500000 329.0000 329.0000
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 4 2.000000 74.0000 55.5000
512 603.500000 29573.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 873 999.500000 47685.7500 384.5000
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 505 606.500000 26544.5000 26544.5000
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
73 136.500000 9496.5000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 578 743.000000 36041.0000 26544.5000
Center 57
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 1 0.500000 18.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 28 36.750000 1416.2500 0.0000
P 98 120.250000 5764.5000 5764.5000
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 17.000000 972.0000 972.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 133 174.500000 8171.2500 6736.5000