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:TPIN
Eligibility Filter:Not Part C
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Screening, Eval, and Assessment,Class #02
EVAL-96111-DEVELOPMENTAL EVALUATION 1 2.000000 100.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 2 4.000000 300.0000 75.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 5 9.000000 675.0000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 3 5.500000 412.5000 75.0000
IPDEF-T1024TLTSGT-F/U PHYC AND DEV EVAL BY EI PROF 4 6.000000 450.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 1 2.000000 111.0000 55.5000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 5 9.000000 319.1300 35.4589
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 14 24.500000 1837.5000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 126 213.656266 15809.2200 73.9937
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 7 11.000000 825.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 71 116.844667 8763.3500 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 3 4.500000 337.5000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 39 69.000000 5015.0000 72.6812
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 14 22.500000 1248.7500 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 100 172.000000 9446.0000 54.9186
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 4 7.000000 525.0000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 49 86.500000 6487.5000 75.0000
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 1 1.000000 304.0000 304.0000
Subtotal (Total Children Is Unduplicated) 251 766.000933 52966.4500 69.1467
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EI Services,Class #03
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 1 2.000000 100.0000 50.0000
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 1 2.000000 142.8800 71.4400
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 1 1.500000 107.1600 71.4400
Subtotal (Total Children Is Unduplicated) 2 5.500000 350.0400 63.6436
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Total 771.500933 53316.4900 69.1075
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Number of Children (Unduplicated) With at Least One Service 253
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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 2 3.000000 225.0000 225.0000
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 10 14.500000 1058.2500 0.0000
T 4 7.000000 447.0000 447.0000
4 8.000000 561.0000 0.0000
Other 1 1.000000 75.0000 0.0000
---------------------------------------------------------
Total 21 33.500000 2366.2500 672.0000
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 1 2.000000 150.0000 150.0000
0 0.000000 0.0000 0.0000
Other 1 2.000000 111.0000 0.0000
---------------------------------------------------------
Total 2 4.000000 261.0000 150.0000
Center 03
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 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
42 65.000000 4875.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 42 65.000000 4875.0000 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 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
7 7.000000 754.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 7 7.000000 754.0000 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 3 1.500000 107.1600 107.1600
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
54 64.000000 4412.6300 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 57 65.500000 4519.7900 107.1600
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 2 4.000000 300.0000 0.0000
T 0 0.000000 0.0000 0.0000
4 7.500000 562.5000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 8 15.500000 1162.5000 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 19 34.500000 1829.3800 1881.3800
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 7 13.000000 813.0000 558.0000
11 21.000000 1380.0000 0.0000
Other 4 7.500000 523.5000 0.0000
---------------------------------------------------------
Total 41 76.000000 4545.8800 2439.3800
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
67 133.500000 9310.5000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 67 133.500000 9310.5000 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 0 0.000000 0.0000 0.0000
P 4 8.000000 456.0000 398.4400
D 7 13.000000 721.5000 0.0000
S 0 0.000000 0.0000 0.0000
H 12 24.000000 1683.0000 0.0000
T 19 36.000000 2406.7500 2226.7500
9 17.500000 1117.5000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 51 98.500000 6384.7500 2625.1900
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
21 34.500000 2274.2500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 21 34.500000 2274.2500 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 0 0.000000 0.0000 0.0000
25 49.000000 3499.5000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 25 49.000000 3499.5000 0.0000
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 9 18.000000 1350.0000 1350.0000
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 12 24.000000 1800.0000 0.0000
T 0 0.000000 0.0000 0.0000
27 46.000933 3361.0700 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 48 88.000933 6511.0700 1350.0000
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 0 0.000000 0.0000 0.0000
76 101.500000 6852.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 76 101.500000 6852.0000 0.0000