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:TPIN
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 1 4.500000 166.5000 37.0000
Subtotal (Total Children Is Unduplicated) 1 4.500000 166.5000 37.0000
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Screening, Eval, and Assessment,Class #02
EVAL-96111-DEVELOPMENTAL EVALUATION 3 8.000000 400.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 7 13.000000 975.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 2 4.500000 337.5000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 2 3.500000 262.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 5 8.500000 637.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 8 17.000000 927.0000 54.5294
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 99 164.377768 11687.8200 71.1034
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 29 44.490800 3213.6600 72.2320
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 42 63.500000 4762.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 101 172.020000 9449.5800 54.9330
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 63 86.000000 7317.1600 85.0833
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 4 4.000000 769.9900 192.4975
Subtotal (Total Children Is Unduplicated) 211 588.888568 40740.2100 69.1815
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Total 593.388568 40906.7100 68.9375
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Number of Children (Unduplicated) With at Least One Service 211
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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 0 0.000000 0.0000 0.0000
P 16 29.000000 1603.6700 1603.6700
D 2 3.000000 186.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 12 17.000000 1226.2500 0.0000
T 2 3.500000 166.5000 83.2500
4 5.000000 345.7500 0.0000
Other 2 3.000000 195.7500 0.0000
---------------------------------------------------------
Total 38 60.500000 3723.9200 1686.9200
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 1 2.000000 150.0000 150.0000
0 0.000000 0.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 1 2.000000 150.0000 150.0000
Center 04
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 0 0.000000 0.0000 0.0000
P 11 11.000000 2094.1500 2094.1500
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
16 18.000000 1579.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 27 29.000000 3673.1500 2094.1500
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
24 31.000000 2081.2500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 24 31.000000 2081.2500 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 0 0.000000 0.0000 0.0000
P 3 5.000000 375.0000 375.0000
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 3 5.000000 375.0000 375.0000
Center 09
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 0 0.000000 0.0000 0.0000
P 48 73.500000 4733.7500 4733.7500
D 1 1.500000 112.5000 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
9 13.500000 865.0000 0.0000
Other 28 39.500000 2962.5000 0.0000
---------------------------------------------------------
Total 86 128.000000 8673.7500 4733.7500
Center 10
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 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
60 117.000000 7917.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 60 117.000000 7917.0000 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 5 10.000000 672.0000 345.2300
D 3 5.500000 305.2500 0.0000
S 0 0.000000 0.0000 0.0000
H 4 7.500000 494.2500 0.0000
T 14 26.500000 1578.1100 1470.1100
19 34.000000 1983.3100 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 45 83.500000 5032.9200 1815.3400
Center 53
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 1 1.500000 112.5000 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
12 19.500000 1316.2500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 13 21.000000 1428.7500 0.0000
Center 54
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 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 2 2.500000 187.5000 187.5000
T 3 5.500000 363.7500 363.7500
31 45.520000 2843.0800 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 36 53.520000 3394.3300 551.2500
Center 55
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 0 0.000000 0.0000 0.0000
P 14 28.000000 2050.0000 2050.0000
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 28.868568 2015.1400 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 37 56.868568 4065.1400 2050.0000
Center 57
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 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 2 4.000000 261.0000 261.0000
2 2.000000 130.5000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 4 6.000000 391.5000 261.0000