CMS/EIP Fiscal Report Statewide
Services beginning 04/01/2018 ending 06/30/2018 Date of Report:08/10/2018 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 917 3588.000000 132756.0000 37.0000
Subtotal (Total Children Is Unduplicated) 917 3588.000000 132756.0000 37.0000
-----------------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 21 37.000000 2775.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 6 10.500000 787.5000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 3 5.500000 412.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 9 18.500000 1387.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 27 45.500000 2525.2500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 321 519.924000 38974.5900 74.9621
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 174 263.000000 19738.1500 75.0500
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 97 147.000000 11025.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 413 621.500000 34465.5000 55.4554
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 177 266.500000 19987.5000 75.0000
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 1 1.000000 53.5500 53.5500
SCREEN-T1023-SCREENING 6 6.000000 300.0000 50.0000
Subtotal (Total Children Is Unduplicated) 656 1941.924000 132432.0400 68.1963
-----------------------------------------------------------------------------------------------------------------------
EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 2 3.000000 150.0000 50.0000
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 1 1.000000 71.4400 71.4400
Subtotal (Total Children Is Unduplicated) 3 4.000000 221.4400 55.3600
-----------------------------------------------------------------------------------------------------------------------
Total 5533.924000 265409.4800 47.9604
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 936
-----------------------------------------------------------------------------------------------------------------------
Center 01
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 305 287.500000 12311.7500 0.0000
P 0 0.000000 0.0000 0.0000
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
2 2.500000 149.5000 0.0000
Other 27 41.000000 2587.5000 0.0000
---------------------------------------------------------
Total 335 331.250000 15058.0000 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 185 161.000000 7190.2500 0.0000
---------------------------------------------------------
Total 185 161.000000 7190.2500 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 212 220.000000 9162.7500 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
30 52.500000 3654.7500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 242 272.500000 12817.5000 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 134 299.250000 11176.0000 0.0000
P 140 175.000000 9089.5000 9089.5000
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
77 125.500000 5402.3000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 351 599.750000 25667.8000 9089.5000
Center 05
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 202 184.500000 8213.5000 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
0 0.000000 0.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 202 184.500000 8213.5000 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
190 198.750000 9568.2500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 190 198.750000 9568.2500 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 4 7.250000 496.2500 0.0000
P 296 357.500000 16573.2500 16573.2500
D 0 0.000000 0.0000 0.0000
S 3 4.250000 231.2500 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
4 8.000000 524.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 307 377.000000 17824.7500 16573.2500
Center 09
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 25 42.750000 1581.7500 0.0000
P 240 401.500000 18786.5000 18786.5000
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
16 23.500000 1762.5000 0.0000
Other 60 96.000000 7034.2500 0.0000
---------------------------------------------------------
Total 341 563.750000 29165.0000 18786.5000
Center 10
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 1 0.500000 18.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 439 470.750000 22116.0000 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 440 471.250000 22134.5000 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 126 89.500000 3768.5000 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
28 28.000000 2100.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 154 117.500000 5868.5000 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 3 2.250000 83.2500 0.0000
P 181 216.000000 10515.7900 10515.7900
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 1 1.000000 88.1500 0.0000
T 0 0.000000 0.0000 0.0000
11 20.500000 1498.5000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 196 239.750000 12185.6900 10515.7900
Center 53
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 1 0.250000 9.2500 9.2500
P 327 345.250000 16406.2500 16406.2500
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
31 43.750000 2592.7500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 359 389.250000 19008.2500 16415.5000
Center 54
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 333 353.000000 15478.2500 0.0000
P 275 290.750000 13517.0000 13517.0000
D 0 0.000000 0.0000 0.0000
S 12 16.000000 896.0000 896.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
85 131.500000 7980.7500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 705 791.250000 37872.0000 14413.0000
Center 55
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 22 26.750000 989.7500 0.0000
P 443 552.412000 24815.4000 24815.4000
D 0 0.000000 0.0000 0.0000
S 1 0.762000 57.1500 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
103 203.500000 14342.9400 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 569 783.424000 40205.2400 24815.4000
Center 57
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 74.0000 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
46 51.000000 2556.2500 522.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 47 53.000000 2630.2500 522.0000