CMS/EIP Fiscal Report Statewide
Services beginning 01/01/2019 ending 03/31/2019 Date of Report:05/04/2019 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 988 3891.251890 143967.0700 36.9976
Subtotal (Total Children Is Unduplicated) 988 3891.251890 143967.0700 36.9976
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 18 27.000000 2025.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 4 7.000000 525.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 5 8.500000 637.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 9 14.000000 1050.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 26 38.000000 2109.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 401 610.700000 45765.0000 74.9386
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 196 300.000000 22500.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 74 117.000000 8775.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 510 737.000000 40792.5000 55.3494
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 173 260.500000 19537.5000 75.0000
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 3 3.000000 176.7300 58.9100
SCREEN-T1023-SCREENING 4 5.000000 250.0000 50.0000
Subtotal (Total Children Is Unduplicated) 734 2127.700000 144143.2300 67.7460
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 2 4.000000 200.0000 50.0000
Subtotal (Total Children Is Unduplicated) 2 4.000000 200.0000 50.0000
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Total 6022.951890 288310.3000 47.8686
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Number of Children (Unduplicated) With at Least One Service 1018
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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 22 13.750000 508.7500 0.0000
P 6 4.500000 166.5000 166.5000
D 0 0.000000 0.0000 0.0000
S 9 8.250000 570.7500 0.0000
H 279 257.750000 11523.7500 10682.0000
T 0 0.000000 0.0000 0.0000
0 0.000000 0.0000 0.0000
Other 25 35.500000 2184.7500 55.5000
---------------------------------------------------------
Total 341 319.750000 14954.5000 10904.0000
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 176 129.500000 5749.5000 0.0000
---------------------------------------------------------
Total 176 129.500000 5749.5000 0.0000
Center 03
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 15 11.500000 425.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 496 535.250000 26174.2500 0.0000
P 43 48.000000 2453.5000 2453.5000
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
3 3.250000 234.2500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 557 598.000000 29287.5000 2453.5000
Center 04
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 201 351.500000 14787.2500 0.0000
P 23 39.500000 1489.7500 1489.7500
D 0 0.000000 0.0000 0.0000
S 1 3.500000 129.5000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
203 308.000000 14117.7300 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 428 702.500000 30524.2300 1489.7500
Center 05
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 1 1.000000 75.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 101 88.750000 3397.7500 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 1 1.000000 37.0000 0.0000
---------------------------------------------------------
Total 103 90.750000 3509.7500 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
119 131.250000 6297.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 119 131.250000 6297.0000 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 85 108.250000 5081.2500 0.0000
P 165 208.750000 10307.0000 10156.2500
D 0 0.000000 0.0000 0.0000
S 2 2.750000 101.7500 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
3 1.500000 55.5000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 255 321.250000 15545.5000 10156.2500
Center 09
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 29 41.750000 2947.7500 606.7500
P 214 369.000000 16564.2500 19235.5000
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
7 13.500000 1012.5000 450.0000
Other 59 89.500000 6381.0000 0.0000
---------------------------------------------------------
Total 309 513.750000 26905.5000 20292.2500
Center 10
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 9 9.250000 342.2500 0.0000
U 0 0.000000 0.0000 0.0000
B 57 52.000000 2114.0000 0.0000
P 216 255.750000 12249.7500 11942.5000
D 14 18.250000 1081.0000 0.0000
S 55 72.500000 3285.5000 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 351 407.750000 19072.5000 11942.5000
Center 51
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 29 20.500000 879.2500 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
4 4.000000 300.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 33 24.500000 1179.2500 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 128 160.500000 7605.5000 0.0000
P 100 123.750000 6240.5000 6240.6200
D 1 1.750000 64.7500 0.0000
S 0 0.000000 0.0000 0.0000
H 8 10.000000 482.5000 0.0000
T 0 0.000000 0.0000 0.0000
40 66.000000 4293.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 277 362.000000 18686.2500 6240.6200
Center 53
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 110 117.000000 5472.7500 0.0000
P 181 193.750000 8948.7500 8750.6000
D 4 3.250000 138.7500 0.0000
S 8 7.750000 286.7500 286.7500
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
60 68.750000 3779.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 363 390.500000 18626.0000 9037.3500
Center 54
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 250 264.250000 11746.7500 18.5000
P 297 295.000000 12530.2500 12716.7500
D 17 17.750000 656.7500 0.0000
S 24 15.750000 582.7500 582.7500
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
226 278.750000 14824.5000 0.0000
Other 2 3.000000 166.5000 0.0000
---------------------------------------------------------
Total 816 874.500000 40507.5000 13318.0000
Center 55
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 219 296.775135 13792.6800 0.0000
P 167 193.676755 9224.1400 9211.5300
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
99 195.000000 13614.0000 0.0000
Other 1 2.500000 92.5000 92.5000
---------------------------------------------------------
Total 486 687.951890 36723.3200 9304.0300
Center 57
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 116 191.500000 8092.7500 0.0000
P 191 273.500000 12388.2500 11824.8000
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
2 4.000000 261.0000 261.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 309 469.000000 20742.0000 12085.8000