CMS/EIP Fiscal Report Statewide
Services beginning 10/01/2019 ending 12/31/2019 Date of Report:02/01/2020 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 6 12.750000 471.7500 37.0000
Subtotal (Total Children Is Unduplicated) 6 12.750000 471.7500 37.0000
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Screening, Eval, and Assessment,Class #02
EVAL-96111-DEVELOPMENTAL EVALUATION 2 3.000000 150.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 4 5.000000 375.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 2 2.500000 187.5000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 3 3.000000 225.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 2 3.000000 225.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 5 7.500000 416.2500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 136 221.343201 16295.7400 73.6220
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 69 124.701467 9174.9300 73.5752
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 39 60.500000 4502.5000 74.4215
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 165 271.500000 14857.2500 54.7228
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 65 101.000000 7580.8900 75.0583
Subtotal (Total Children Is Unduplicated) 269 803.044668 53990.0600 67.2317
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Total 815.794668 54461.8100 66.7592
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Number of Children (Unduplicated) With at Least One Service 269
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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 25.500000 1667.2500 1667.2500
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 12 17.000000 1187.2500 0.0000
T 1 1.500000 112.5000 112.5000
6 8.000000 570.7500 0.0000
Other 4 4.500000 337.5000 0.0000
---------------------------------------------------------
Total 39 56.500000 3875.2500 1779.7500
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 4 8.000000 600.0000 600.0000
0 0.000000 0.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 4 8.000000 600.0000 600.0000
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 1 1.000000 267.7400 267.7400
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 12.500000 918.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 13 13.500000 1185.7400 267.7400
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
64 75.500000 5204.2500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 64 75.500000 5204.2500 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 2 4.000000 300.0000 300.0000
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 2 4.000000 300.0000 300.0000
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 33 51.000000 2903.5700 3102.2900
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
5 6.000000 331.7500 0.0000
Other 20 30.500000 2287.5000 0.0000
---------------------------------------------------------
Total 58 87.500000 5522.8200 3102.2900
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
93 167.000000 11091.7500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 93 167.000000 11091.7500 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 4 8.000000 600.0000 399.3500
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 19 38.000000 2850.0000 0.0000
T 22 43.000000 2554.7300 2414.7300
22 43.000000 2480.4200 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 67 132.000000 8485.1500 2814.0800
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 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
51 72.500000 4615.7500 0.0000
Other 2 2.000000 101.7500 0.0000
---------------------------------------------------------
Total 53 74.500000 4717.5000 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 0 0.000000 0.0000 0.0000
T 5 8.000000 483.0000 483.0000
31 48.250000 3218.7500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 36 56.250000 3701.7500 483.0000
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 6 12.000000 900.0000 900.0000
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 5 10.000000 750.0000 0.0000
T 0 0.000000 0.0000 0.0000
29 50.044668 3664.3500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 40 72.044668 5314.3500 900.0000
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 4 8.000000 522.0000 522.0000
52 61.000000 3941.2500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 56 69.000000 4463.2500 522.0000