CMS/EIP Fiscal Report Statewide
Services beginning 01/01/2018 ending 03/31/2018 Date of Report:05/05/2018 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 879 3565.500000 131851.5000 36.9798
Subtotal (Total Children Is Unduplicated) 879 3565.500000 131851.5000 36.9798
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 15 25.000000 1875.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 10 14.500000 1087.5000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 6 10.000000 750.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 5 7.500000 562.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 16 25.500000 1415.2500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 301 453.500000 33917.7900 74.7912
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 143 211.500000 15838.1500 74.8849
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 103 164.000000 12300.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 387 574.500000 31884.7500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 174 247.500000 18562.5000 75.0000
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 10 10.000000 535.5000 53.5500
SCREEN-T1023-SCREENING 8 9.000000 450.0000 50.0000
Subtotal (Total Children Is Unduplicated) 623 1752.500000 119178.9400 68.0051
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 5 42.250000 2112.5000 50.0000
PHY-97110HM-PT SESSION BY PT ASST 2 1.500000 85.7400 57.1600
Subtotal (Total Children Is Unduplicated) 7 43.750000 2198.2400 50.2455
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Total 5361.750000 253228.6800 47.2287
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Number of Children (Unduplicated) With at Least One Service 924
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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 352 280.250000 11117.5000 0.0000
P 17 23.000000 1695.7500 1695.7500
D 0 0.000000 0.0000 0.0000
S 1 1.500000 112.5000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
2 0.750000 27.7500 0.0000
Other 36 46.000000 2894.2500 0.0000
---------------------------------------------------------
Total 408 351.500000 15847.7500 1695.7500
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 182 166.000000 7595.5000 0.0000
---------------------------------------------------------
Total 182 166.000000 7595.5000 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 349 370.250000 16539.5000 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
2 2.000000 100.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 351 372.250000 16639.5000 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 8 25.250000 934.2500 0.0000
P 262 473.000000 19556.3500 19602.6700
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 4 15.000000 750.0000 0.0000
T 0 0.000000 0.0000 0.0000
54 48.500000 2971.6500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 328 561.750000 24212.2500 19602.6700
Center 05
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 3 2.500000 92.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 184 165.750000 7462.7500 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 187 168.250000 7555.2500 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
122 138.000000 6649.2500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 122 138.000000 6649.2500 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 1 1.500000 112.5000 0.0000
P 308 358.250000 16089.0000 16089.0000
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 4.500000 166.5000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 312 364.250000 16368.0000 16089.0000
Center 09
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 1 2.000000 150.0000 0.0000
P 192 339.250000 16027.0000 16027.0020
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
8 14.000000 952.5000 0.0000
Other 54 85.000000 6238.5000 0.0000
---------------------------------------------------------
Total 255 440.250000 23368.0000 16027.0020
Center 10
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 495 528.000000 24436.7500 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
5 19.500000 955.5000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 500 547.500000 25392.2500 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 154 117.250000 4880.2500 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
23 25.250000 1751.2500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 177 142.500000 6631.5000 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 0 0.000000 0.0000 0.0000
P 241 287.500000 13388.1900 13388.1900
D 0 0.000000 0.0000 0.0000
S 4 8.000000 561.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
12 22.000000 1650.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 257 317.500000 15599.1900 13388.1900
Center 53
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 44 31.750000 1174.7500 0.0000
P 238 264.250000 12362.0000 12362.0000
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
45 66.000000 4055.5000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 327 362.000000 17592.2500 12362.0000
Center 54
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 324 293.250000 12127.2500 0.0000
P 64 70.250000 3843.0000 3843.0000
D 0 0.000000 0.0000 0.0000
S 22 31.000000 2249.0000 2249.0000
H 3 2.250000 83.2500 83.2500
T 0 0.000000 0.0000 0.0000
133 172.500000 9060.2500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 546 569.250000 27362.7500 6175.2500
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 4.500000 166.5000 0.0000
P 490 586.750000 26047.0000 25973.0000
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
89 169.500000 11710.7400 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 582 760.750000 37924.2400 25973.0000
Center 57
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 69 94.500000 4117.5000 0.0000
P 2 1.500000 112.5000 112.5000
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
2 4.000000 261.0000 261.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 73 100.000000 4491.0000 373.5000