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
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 895 3492.000000 129102.2500 36.9709
Subtotal (Total Children Is Unduplicated) 895 3492.000000 129102.2500 36.9709
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 26 42.000000 3150.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 13 18.000000 1350.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 2.000000 150.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 10 14.500000 1087.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 30 49.500000 2747.2500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 354 562.000000 42150.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 178 276.500000 20737.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 91 148.500000 11137.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 455 680.500000 37712.2500 55.4184
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 158 226.500000 16987.5000 75.0000
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 2 2.000000 117.8200 58.9100
SCREEN-T1023-SCREENING 2 2.000000 100.0000 50.0000
Subtotal (Total Children Is Unduplicated) 675 2024.000000 137427.3200 67.8989
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 2 6.000000 300.0000 50.0000
Subtotal (Total Children Is Unduplicated) 2 6.000000 300.0000 50.0000
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Total 5522.000000 266829.5700 48.3212
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Number of Children (Unduplicated) With at Least One Service 928
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Center 01
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 15 8.500000 314.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 44 53.250000 3800.0000 0.0000
P 239 195.000000 7215.0000 7215.0000
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 0.500000 18.5000 0.0000
Other 29 39.500000 2348.2500 0.0000
---------------------------------------------------------
Total 328 296.750000 13696.2500 7215.0000
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 127 113.500000 5401.0000 0.0000
---------------------------------------------------------
Total 127 113.500000 5401.0000 0.0000
Center 03
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 5 5.000000 185.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 415 464.000000 22007.7500 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
12 21.500000 1476.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 432 490.500000 23668.7500 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 61 103.000000 4404.2500 0.0000
P 207 383.750000 15356.5000 15356.5000
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
61 51.250000 3268.3200 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 329 538.000000 23029.0700 15356.5000
Center 05
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 135 118.750000 4792.7500 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 135 118.750000 4792.7500 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
180 206.750000 10111.5000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 180 206.750000 10111.5000 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 0.500000 18.5000 0.0000
P 273 327.500000 15515.5000 15515.5000
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
4 2.750000 101.7500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 278 330.750000 15635.7500 15515.5000
Center 09
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 13 18.500000 684.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 76 135.000000 6259.0000 0.0000
P 134 229.500000 10856.5000 10856.5600
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 8.500000 598.5000 0.0000
Other 65 98.500000 7299.7500 0.0000
---------------------------------------------------------
Total 294 490.000000 25698.2500 10856.5600
Center 10
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 18 19.250000 712.2500 0.0000
U 0 0.000000 0.0000 0.0000
B 301 379.750000 19006.5000 0.0000
P 0 0.000000 0.0000 0.0000
D 0 0.000000 0.0000 0.0000
S 10 20.750000 1200.7500 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
3 4.500000 298.5000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 332 424.250000 21218.0000 0.0000
Center 51
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 4 1.750000 64.7500 0.0000
U 0 0.000000 0.0000 0.0000
B 55 48.500000 1998.0000 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
27 27.250000 1957.2500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 86 77.500000 4020.0000 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 78 112.250000 6386.2500 0.0000
P 189 222.250000 9438.7500 9438.7500
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
30 58.500000 4114.5000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 297 393.000000 19939.5000 9438.7500
Center 53
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 64 73.500000 3176.7500 27.7500
P 202 242.000000 11417.7500 11417.7500
D 0 0.000000 0.0000 0.0000
S 2 1.500000 55.5000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
44 55.500000 3080.5000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 312 372.500000 17730.5000 11445.5000
Center 54
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 183 185.000000 7642.5000 0.0000
P 320 341.000000 15437.0000 15437.0000
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
115 150.750000 8341.0000 0.0000
Other 2 2.500000 92.5000 0.0000
---------------------------------------------------------
Total 620 679.250000 31513.0000 15437.0000
Center 55
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 0 0.000000 0.0000 0.0000
P 478 543.000000 24764.0000 24764.0000
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
105 210.000000 14892.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 583 753.000000 39656.0000 24764.0000
Center 57
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 131 188.000000 7539.0000 0.0000
P 47 48.500000 3105.2500 3105.2500
D 1 1.000000 75.0000 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 179 237.500000 10719.2500 3105.2500