CMS/EIP Fiscal Report Statewide
Services beginning 10/01/2020 ending 12/31/2020 Date of Report:01/23/2021 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 697 3279.750000 121276.7500 36.9774
Subtotal (Total Children Is Unduplicated) 697 3279.750000 121276.7500 36.9774
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 1 2.000000 150.0000 75.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 12 21.500000 1612.5000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 4 7.000000 525.0000 75.0000
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 3 5.500000 412.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 1 1.500000 112.5000 75.0000
IPDEF-T1024TLTSGT-F/U PHYC AND DEV EVAL BY EI PROF 2 5.000000 375.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 3 6.000000 333.0000 55.5000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 5 9.000000 499.5000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 19 30.000000 2250.0000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 281 475.836800 35687.7600 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 15 24.000000 1800.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 152 248.622000 18646.6500 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 6 11.000000 825.0000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 100 165.500000 12412.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 46 79.000000 4384.5000 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 304 487.000100 27028.5055 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 19 31.500000 2362.5000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 104 167.500000 12562.5000 75.0000
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 1 1.000000 58.9100 58.9100
Subtotal (Total Children Is Unduplicated) 550 1778.458900 122038.8255 68.6205
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 3 4.000000 200.0000 50.0000
Subtotal (Total Children Is Unduplicated) 3 4.000000 200.0000 50.0000
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Total 5062.208900 243515.5755 48.1046
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Number of Children (Unduplicated) With at Least One Service 734
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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 0 0.000000 0.0000 0.0000
D 0 0.000000 0.0000 0.0000
S 185 170.500000 8409.0000 0.0000
H 226 196.750000 8576.0000 7817.5000
T 0 0.000000 0.0000 0.0000
1 0.250000 9.2500 0.0000
Other 49 48.750000 3022.0000 0.0000
---------------------------------------------------------
Total 461 416.250000 20016.2500 7817.5000
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 103 105.250000 5457.2500 0.0000
---------------------------------------------------------
Total 103 105.250000 5457.2500 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 135 180.000000 8091.2500 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
0 0.000000 0.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 135 180.000000 8091.2500 0.0000
Center 04
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 4 7.000000 259.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 121 199.500000 8409.7500 0.0000
P 28 50.500000 1981.5000 1981.5000
D 6 10.500000 388.5000 0.0000
S 0 0.000000 0.0000 0.0000
H 3 4.000000 200.0000 0.0000
T 0 0.000000 0.0000 0.0000
26 36.000000 1947.6600 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 188 307.500000 13186.4100 1981.5000
Center 05
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 1 1.000000 75.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 136 133.500000 5167.5000 1110.0000
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 137 134.500000 5242.5000 1110.0000
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
395 398.000000 18610.2500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 395 398.000000 18610.2500 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 37 40.750000 1659.7500 0.0000
P 106 138.000000 6610.0000 6610.0000
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
3 4.500000 242.5000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 146 183.250000 8512.2500 6610.0000
Center 09
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 31 54.250000 2044.2500 0.0000
P 83 144.500000 6974.0000 6974.0000
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 2 4.000000 222.0000 55.5000
12 24.000000 1800.0000 0.0000
Other 48 91.000000 6571.5000 0.0000
---------------------------------------------------------
Total 176 317.750000 17611.7500 7029.5000
Center 10
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 20 21.750000 918.7500 0.0000
U 0 0.000000 0.0000 0.0000
B 50 63.250000 2613.0000 0.0000
P 311 355.500000 17289.2500 17023.9500
D 14 19.000000 1356.7500 0.0000
S 18 32.500000 2164.5000 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 413 492.000000 24342.2500 17023.9500
Center 51
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 10 8.500000 569.2500 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
21 18.000000 825.2500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 31 26.500000 1394.5000 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 20 28.500000 1460.7500 0.0000
P 81 133.500000 6552.2500 6552.2800
D 0 0.000000 0.0000 0.0000
S 8 8.750000 379.7500 33.7500
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
16 31.000000 2130.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 125 201.750000 10522.7500 6586.0300
Center 53
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 217 227.500000 10722.0000 0.0000
P 121 129.250100 6141.7555 6141.7500
D 12 15.500000 847.2500 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 9.500000 605.2500 0.0000
Other 1 1.000000 55.5000 0.0000
---------------------------------------------------------
Total 356 382.750100 18371.7555 6141.7500
Center 54
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 231 261.500000 11873.0000 0.0000
P 152 184.000000 8327.0000 8327.0000
D 6 11.000000 825.0000 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 51.000000 3135.7500 0.0000
Other 1 2.000000 150.0000 0.0000
---------------------------------------------------------
Total 420 509.500000 24310.7500 8327.0000
Center 55
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 430 544.000000 25904.0000 0.0000
P 69 85.000000 3677.0000 21939.2500
D 0 0.000000 0.0000 0.0000
S 1 0.836800 62.7600 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
92 181.872000 12265.9000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 592 811.708800 41909.6600 21939.2500
Center 57
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 99 174.750000 6919.2500 0.0000
P 279 420.750000 19016.7500 18968.6500
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 378 595.500000 25936.0000 18968.6500