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
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 878 3503.500000 129474.2500 36.9557
Subtotal (Total Children Is Unduplicated) 878 3503.500000 129474.2500 36.9557
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 22 33.500000 2512.5000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 5 9.000000 675.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 3 4.500000 337.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 13 23.000000 1725.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 29 45.000000 2497.5000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 308 456.500000 34237.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 155 224.500000 16837.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 88 131.000000 9825.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 406 585.000000 32455.2500 55.4791
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 200 279.500000 20962.5000 75.0000
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 10 10.000000 535.5000 53.5500
Subtotal (Total Children Is Unduplicated) 636 1801.500000 122600.7500 68.0548
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 4 25.000000 1250.0000 50.0000
PHY-97110HM-PT SESSION BY PT ASST 2 13.000000 743.0800 57.1600
Subtotal (Total Children Is Unduplicated) 6 38.000000 1993.0800 52.4495
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Total 5343.000000 254068.0800 47.5516
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Number of Children (Unduplicated) With at Least One Service 906
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Center 01
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 1 2.000000 150.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 261 240.750000 9711.5000 0.0000
P 2 2.500000 158.2500 158.2500
D 0 0.000000 0.0000 0.0000
S 6 4.000000 262.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
12 13.250000 916.5000 0.0000
Other 8 11.500000 726.0000 0.0000
---------------------------------------------------------
Total 290 274.000000 11924.2500 158.2500
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 99 91.000000 4065.0000 0.0000
---------------------------------------------------------
Total 99 91.000000 4065.0000 0.0000
Center 03
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 4 3.000000 111.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 283 275.000000 12300.0000 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 287 278.000000 12411.0000 0.0000
Center 04
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 4 15.500000 573.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 42 72.750000 3106.2500 0.0000
P 276 515.250000 21222.9000 21264.7800
D 0 0.000000 0.0000 0.0000
S 1 2.000000 74.0000 0.0000
H 3 13.000000 650.0000 0.0000
T 0 0.000000 0.0000 0.0000
59 47.500000 3002.8500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 385 666.000000 28629.5000 21264.7800
Center 05
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 218 184.000000 8271.0000 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
1 0.250000 9.2500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 219 184.250000 8280.2500 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
130 131.000000 6312.2500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 130 131.000000 6312.2500 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 3 0.750000 27.7500 0.0000
P 385 437.500000 20537.7500 20537.7500
D 0 0.000000 0.0000 0.0000
S 1 0.250000 9.2500 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 389 438.500000 20574.7500 20537.7500
Center 09
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 0 0.000000 0.0000 0.0000
P 189 321.000000 15248.5000 15248.5000
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
5 8.500000 637.5000 0.0000
Other 44 64.000000 4722.0000 0.0000
---------------------------------------------------------
Total 238 393.500000 20608.0000 15248.5000
Center 10
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 1 2.750000 101.7500 0.0000
U 0 0.000000 0.0000 0.0000
B 387 473.250000 22706.2500 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
1 1.250000 46.2500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 389 477.250000 22854.2500 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 39 35.250000 1470.7500 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
11 11.000000 825.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 50 46.250000 2295.7500 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 9 14.500000 897.5000 0.0000
P 208 259.500000 12185.7500 12185.7500
D 4 6.750000 382.7500 0.0000
S 8 7.750000 286.7500 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
19 28.000000 1891.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 248 316.500000 15643.7500 12185.7500
Center 53
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 101 102.250000 4699.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 24 22.000000 898.7500 0.0000
P 122 154.750000 7822.2500 7822.2500
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
152 184.250000 9482.5000 0.0000
Other 1 0.250000 9.2500 0.0000
---------------------------------------------------------
Total 400 463.500000 22911.7500 7822.2500
Center 54
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 150 156.750000 6852.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 333 317.250000 15207.5000 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
309 369.750000 18520.2500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 792 843.750000 40579.7500 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 1 0.500000 18.5000 0.0000
P 395 498.750000 22177.7500 22177.7500
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
92 141.500000 9875.5800 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 488 640.750000 32071.8300 22177.7500
Center 57
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 63 80.250000 3741.2500 0.0000
P 5 6.500000 381.7500 381.7500
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
6 12.000000 783.0000 783.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 74 98.750000 4906.0000 1164.7500