CMS/EIP Fiscal Report Statewide
Services beginning 07/01/2017 ending 09/30/2017 Date of Report:11/05/2017 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 952 3704.750000 136994.5000 36.9781
Subtotal (Total Children Is Unduplicated) 952 3704.750000 136994.5000 36.9781
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 15 24.500000 1837.5000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 3 4.500000 337.5000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 7 11.000000 825.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 7 10.000000 750.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 14 21.000000 1165.5000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 277 402.500000 30187.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 106 138.000000 10300.0000 74.6377
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 87 132.000000 9900.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 384 556.500000 30835.7500 55.4102
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 174 249.000000 18675.0000 75.0000
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 1 1.000000 53.5500 53.5500
OCTF-97168-OT RE-EVAL EST PLAN CARE 1 1.000000 51.0500 51.0500
SCREEN-T1023-SCREENING 4 4.000000 200.0000 50.0000
Subtotal (Total Children Is Unduplicated) 588 1555.000000 105118.3500 67.6002
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 4 30.000000 1500.0000 50.0000
Subtotal (Total Children Is Unduplicated) 4 30.000000 1500.0000 50.0000
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Total 5289.750000 243612.8500 46.0538
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Number of Children (Unduplicated) With at Least One Service 969
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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 364 289.250000 11858.2500 0.0000
P 0 0.000000 0.0000 0.0000
D 0 0.000000 0.0000 0.0000
S 60 54.250000 2121.2500 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
1 1.000000 37.0000 0.0000
Other 2 4.000000 261.0000 0.0000
---------------------------------------------------------
Total 427 348.500000 14277.5000 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 155 131.500000 5703.7500 0.0000
---------------------------------------------------------
Total 155 131.500000 5703.7500 0.0000
Center 03
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 8 11.000000 407.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 227 175.500000 6493.5000 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
43 42.000000 1554.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 278 228.500000 8454.5000 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 17 33.250000 1249.2500 0.0000
P 230 424.250000 17314.7500 17314.7500
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
52 41.500000 2642.5500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 299 499.000000 21206.5500 17314.7500
Center 05
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 151 133.750000 5613.7500 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 151 133.750000 5613.7500 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
193 200.000000 9455.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 193 200.000000 9455.0000 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 4 3.500000 129.5000 0.0000
P 363 426.750000 20185.0000 20185.0000
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
3 4.250000 157.2500 0.0000
Other 1 0.250000 9.2500 0.0000
---------------------------------------------------------
Total 371 434.750000 20481.0000 20185.0000
Center 09
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 1 1.500000 112.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 8 11.750000 652.5000 308.2500
P 254 422.250000 19921.0000 19921.0000
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
14 21.000000 1575.0000 0.0000
Other 44 67.000000 5025.0000 0.0000
---------------------------------------------------------
Total 321 523.500000 27286.0000 20229.2500
Center 10
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 7 4.000000 148.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 362 392.750000 17868.0000 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 369 396.750000 18016.0000 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 109 89.000000 3584.5000 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
19 19.000000 1425.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 128 108.000000 5009.5000 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 62 75.750000 4495.5000 0.0000
P 153 166.000000 7316.7500 7316.7500
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
5 9.000000 675.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 220 250.750000 12487.2500 7316.7500
Center 53
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 59 51.000000 1887.0000 0.0000
P 249 288.000000 13452.0000 13452.0000
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
76 82.250000 4501.5000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 384 421.250000 19840.5000 13452.0000
Center 54
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 695 664.000000 30090.0000 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
119 147.250000 7419.5000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 814 811.250000 37509.5000 0.0000
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 440 542.500000 24100.5000 24100.5000
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
54 102.000000 7177.5500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 494 644.500000 31278.0500 24100.5000
Center 57
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 1 1.000000 37.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 67 86.250000 3548.7500 0.0000
P 51 58.500000 2625.2500 2625.2500
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
6 12.000000 783.0000 783.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 125 157.750000 6994.0000 3408.2500