CMS/EIP Fiscal Report Statewide
Services beginning 10/01/2017 ending 12/31/2017 Date of Report:02/03/2018 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 13096 38638.25000 1428693.7400 36.9762
Subtotal (Total Children Is Unduplicated) 13096 38638.25000 1428693.7400 36.9762
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 71 108.000000 8100.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 38 51.500000 3862.5000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 15 19.500000 1462.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 43 73.500000 5493.0000 74.7347
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 83 118.500000 6576.7500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 1032 1589.000000 119090.0000 74.9465
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 443 655.000000 49125.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 189 276.500000 20737.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 1244 1825.500000 101228.7500 55.4526
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 615 929.500000 69712.5000 75.0000
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 11 11.000000 589.0500 53.5500
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 4 4.000000 106.4400 26.6100
OCTH-97165-OT EVAL LOW COMPLEXITY 2 2.000000 102.1000 51.0500
SCREEN-T1023-SCREENING 43 43.000000 2150.0000 50.0000
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 2 2.000000 102.1000 51.0500
Subtotal (Total Children Is Unduplicated) 2321 5708.500000 388438.1900 68.0456
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EI Services,Class #03
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 5 7.000000 175.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 744 3240.250000 161862.5000 49.9537
OCCT-97530-OT SESSION BY LICENSED OT 19 56.250000 4018.5000 71.4400
OCCT-97530HM-OT SESSION BY OT ASST 1 2.000000 114.4000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 29 69.500000 4965.0800 71.4400
PHY-97110HM-PT SESSION BY PT ASST 3 9.000000 514.4400 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 52 159.000000 11358.9600 71.4400
Subtotal (Total Children Is Unduplicated) 827 3543.000000 183008.8800 51.6536
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Total 47889.750000 2000140.8100 41.7655
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Number of Children (Unduplicated) With at Least One Service 13354
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Center 01
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 4 2.750000 177.7500 0.0000
U 0 0.000000 0.0000 0.0000
B 7546 5116.000000 202441.9600 0.0000
P 104 107.000000 5516.0500 5516.0500
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 7654 5225.750000 208135.7600 5516.0500
Center 03
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 26 30.750000 1488.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 3053 2000.250000 81356.2500 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 3079 2031.000000 82844.7500 0.0000
Center 04
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 44 61.250000 2266.2500 0.0000
U 0 0.000000 0.0000 0.0000
B 621 960.750000 37359.2500 0.0000
P 2941 4661.750000 182921.9900 183076.8700
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 3606 5683.750000 222547.4900 183076.8700
Center 05
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 2793 1788.250000 72312.5000 0.0000
P 3 3.000000 150.0000 150.0000
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 2796 1791.250000 72462.5000 150.0000
Center 07
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 19 12.500000 538.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 11 8.000000 524.0000 0.0000
P 5072 4090.000000 169860.7500 169860.7500
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 5102 4110.500000 170923.2500 169860.7500
Center 09
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 56 61.750000 3084.7500 0.0000
P 4284 4501.250000 188004.2500 188032.5070
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 4340 4563.000000 191089.0000 188032.5070
Center 10
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 32 17.750000 656.7500 0.0000
U 0 0.000000 0.0000 0.0000
B 9267 7488.000000 318596.2500 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 9299 7505.750000 319253.0000 0.0000
Center 51
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 3 2.000000 74.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 1377 901.500000 35234.2500 0.0000
P 3 8.000000 464.3200 364.3200
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 1383 911.500000 35772.5700 364.3200
Center 52
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 75 88.250000 4875.7500 37.0000
P 3045 2828.000000 133618.5000 132310.3000
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 3120 2916.250000 138494.2500 132347.3000
Center 53
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 1048 972.750000 42853.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 238 175.250000 7001.7500 0.0000
P 1670 1697.750000 77286.0000 77286.0000
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 2956 2845.750000 127141.2500 77286.0000
Center 54
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 1535 1276.500000 53894.2500 0.0000
U 0 0.000000 0.0000 0.0000
B 3381 2781.000000 123434.3500 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 4916 4057.500000 177328.6000 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 3 1.250000 46.2500 0.0000
P 3894 3459.250000 140965.5000 140965.5000
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 3897 3460.500000 141011.7500 140965.5000
Center 57
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 2494 2567.000000 102851.0000 0.0000
P 249 220.250000 10285.6400 10285.6900
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 2743 2787.250000 113136.6400 10285.6900