CMS/EIP Fiscal Report Statewide
Services beginning 10/01/2018 ending 12/31/2018 Date of Report:02/06/2019 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 13004 37775.50000 1396288.0000 36.9628
Subtotal (Total Children Is Unduplicated) 13004 37775.50000 1396288.0000 36.9628
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 101 166.000000 12450.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 44 60.000000 4500.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 12 19.000000 1425.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 48 73.500000 5512.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 90 136.000000 7548.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 1126 1830.000000 137250.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 421 613.000000 45975.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 194 317.000000 23775.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 1259 1954.000000 108447.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 650 1080.000000 80962.5000 74.9653
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 4 4.000000 235.6400 58.9100
MED-99204-OUTPATIENT VISIT, NEW, 45 MINS 2 2.000000 166.5800 83.2900
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 4 4.000000 93.6800 23.4200
PSTH-97163-PT EVAL HIGH COMPLEXITY 1 1.000000 51.0500 51.0500
SCREEN-T1023-SCREENING 49 49.000000 2450.0000 50.0000
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 2 2.000000 102.1000 51.0500
Subtotal (Total Children Is Unduplicated) 2519 6310.500000 430944.0500 68.2900
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EI Services,Class #03
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 11 17.000000 425.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 915 4207.750000 210359.1400 49.9933
OCCT-97530-OT SESSION BY LICENSED OT 9 49.500000 3536.2800 71.4400
OCCT-97530HM-OT SESSION BY OT ASST 1 2.000000 114.4000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 24 64.000000 4572.1600 71.4400
PHY-97110HM-PT SESSION BY PT ASST 3 4.000000 228.6400 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 46 180.000000 12859.2000 71.4400
Subtotal (Total Children Is Unduplicated) 987 4524.250000 232094.8200 51.3002
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Total 48610.250000 2059326.8700 42.3640
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Number of Children (Unduplicated) With at Least One Service 13304
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Center 01
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 616 441.250000 18223.0900 0.0000
U 0 0.000000 0.0000 0.0000
B 744 823.000000 50248.6200 0.0000
P 6372 4131.500000 154549.8300 151640.2800
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 7732 5395.750000 223021.5400 151640.2800
Center 03
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 97 72.500000 3254.2500 0.0000
U 0 0.000000 0.0000 0.0000
B 3072 2366.250000 104534.7500 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 3169 2438.750000 107789.0000 0.0000
Center 04
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 8 8.500000 314.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 1207 1769.000000 68749.0000 0.0000
P 2815 4449.500000 176268.8800 173571.3900
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 4030 6227.000000 245332.3800 173571.3900
Center 05
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 65 46.250000 1711.2500 0.0000
U 0 0.000000 0.0000 0.0000
B 2272 1531.500000 60339.2500 0.0000
P 2 2.500000 187.5000 187.5000
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 2339 1580.250000 62238.0000 187.5000
Center 07
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 13 9.500000 351.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 41 36.500000 1439.5000 0.0000
P 3838 3385.250000 144593.8900 144529.1400
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 3892 3431.250000 146384.8900 144529.1400
Center 09
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 202 241.250000 8926.2500 0.0000
U 0 0.000000 0.0000 0.0000
B 1776 1734.250000 68773.0000 124.5000
P 3023 3148.000000 131004.7500 130894.8900
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 5001 5123.500000 208704.0000 131019.3900
Center 10
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 402 317.000000 11729.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 5337 4969.000000 220869.7500 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 5739 5286.000000 232598.7500 0.0000
Center 51
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 230 165.750000 6031.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 626 441.000000 17109.0000 0.0000
P 1 4.000000 285.7600 285.7600
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 857 610.750000 23425.7600 285.7600
Center 52
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 7 3.500000 142.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 1090 1102.500000 54661.5000 83.2500
P 2448 2307.750000 104302.3000 103358.9600
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 3545 3413.750000 159106.3000 103442.2100
Center 53
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 21 18.500000 739.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 837 789.000000 32932.5000 29.7500
P 2858 2922.500000 136970.5000 136933.5000
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 3716 3730.000000 170642.5000 136963.2500
Center 54
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 3 3.000000 150.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 1801 1436.500000 57609.5000 0.0000
P 3997 3525.000000 156606.5000 174968.0000
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 5801 4964.500000 214366.0000 174968.0000
Center 55
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 2 0.500000 18.5000 0.0000
P 3753 3206.500000 135943.5000 135943.5000
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 3755 3207.000000 135962.0000 135943.5000
Center 57
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 1 0.500000 18.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 2298 2819.500000 106232.2500 0.0000
P 365 381.750000 23505.0000 23315.8000
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 2664 3201.750000 129755.7500 23315.8000