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
Agency Filter:EIP DEI DEIP
Payclass Filters:OTHER
Eligibility Filter:Part C (excluding not eligible)
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
CASE-CASE-NON-TCM CASE MANAGEMENT 1 0.500000 18.5000 37.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 127 276.250000 10202.7500 36.9330
Subtotal (Total Children Is Unduplicated) 127 276.750000 10221.2500 36.9332
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 4 6.000000 450.0000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 2 4.000000 300.0000 75.0000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 6 10.500000 582.7500 55.5000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 31 50.500000 3712.5000 73.5149
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 24 43.500000 3262.5000 75.0000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 53 90.000000 4967.2500 55.1917
Subtotal (Total Children Is Unduplicated) 61 204.500000 13275.0000 64.9144
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EI Services,Class #03
CONSF-CONSFGT-CONSULT,SLP,FACE TO FACE 1 0.500000 25.0000 50.0000
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 1 2.000000 142.8800 71.4400
Subtotal (Total Children Is Unduplicated) 2 2.500000 167.8800 67.1520
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Total 483.750000 23664.1300 48.9181
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Number of Children (Unduplicated) With at Least One Service 131
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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 0 0.000000 0.0000 0.0000
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 177 301.000000 16675.0000 0.0000
T 0 0.000000 0.0000 0.0000
167 163.250000 6040.2500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 344 464.250000 22715.2500 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 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 0.500000 25.0000 25.0000
0 0.000000 0.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 1 0.500000 25.0000 25.0000
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 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
16 12.000000 664.8800 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 16 12.000000 664.8800 0.0000
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
7 7.000000 259.0000 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 7 7.000000 259.0000 0.0000