CMS/EIP Fiscal Report Statewide
Services beginning 04/01/2021 ending 06/30/2021 Date of Report:07/15/2021 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
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 4 5.500000 203.5000 37.0000
Subtotal (Total Children Is Unduplicated) 4 5.500000 203.5000 37.0000
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Screening, Eval, and Assessment,Class #02
EVAL-96111-DEVELOPMENTAL EVALUATION 2 4.000000 200.0000 50.0000
EVAL-96111GT-DEVELOPMENTAL EVALUATION 1 2.000000 100.0000 50.0000
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 3 5.500000 412.5000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 2 3.500000 262.5000 75.0000
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 2 3.000000 195.7500 65.2500
IPDEF-T1024TLTSGT-F/U PHYC AND DEV EVAL BY EI PROF 1 1.500000 112.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 1 1.500000 83.2500 55.5000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 4 7.500000 416.2500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 26 48.500000 3637.5000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 158 265.059601 19640.4700 74.0983
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 12 20.000000 1500.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 57 92.000000 6804.9000 73.9663
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 20 35.500000 2662.5000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 62 99.140267 7435.5200 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 22 41.500000 2303.2500 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 169 265.500000 14563.0000 54.8512
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 19 35.500000 2662.5000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 51 76.177900 5713.3425 75.0000
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 6 6.000000 1824.0000 304.0000
SCREEN-T1023-SCREENING 1 1.000000 50.0000 50.0000
Subtotal (Total Children Is Unduplicated) 354 1016.377768 70729.7325 69.5900
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 1 4.000000 200.0000 50.0000
Subtotal (Total Children Is Unduplicated) 1 4.000000 200.0000 50.0000
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Total 1025.877768 71133.2325 69.3389
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Number of Children (Unduplicated) With at Least One Service 359
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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 21 31.000000 1954.5000 1954.5000
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 6 8.500000 569.2500 0.0000
T 7 11.000000 639.7500 639.7500
4 3.500000 224.5000 0.0000
Other 1 1.000000 55.5000 0.0000
---------------------------------------------------------
Total 39 55.000000 3443.5000 2594.2500
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 5 9.500000 712.5000 712.5000
1 2.000000 111.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 6 11.500000 823.5000 712.5000
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
27 45.000000 3350.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 27 45.000000 3350.0000 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
28 32.000000 3744.7500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 28 32.000000 3744.7500 0.0000
Center 05
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
4 4.500000 166.5000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 4 4.500000 166.5000 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
120 172.000000 11739.7500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 120 172.000000 11739.7500 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 3.177900 238.3425 238.3400
D 5 10.000000 750.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 4 8.000000 600.0000 0.0000
T 0 0.000000 0.0000 0.0000
2 4.000000 261.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 13 25.177900 1849.3425 238.3400
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 31 57.500000 3395.7500 3476.7900
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 7.000000 390.9000 0.0000
24 45.000000 2770.5000 0.0000
Other 30 57.000000 3933.7500 0.0000
---------------------------------------------------------
Total 89 166.500000 10490.9000 3476.7900
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
68 132.000000 9120.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 68 132.000000 9120.0000 0.0000
Center 51
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
2 2.000000 130.5000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 2 2.000000 130.5000 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 3 6.000000 372.0000 319.2200
D 3 6.000000 333.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 16 31.000000 2149.5000 0.0000
T 12 22.000000 1533.0000 1371.0000
5 10.000000 633.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 39 75.000000 5020.5000 1690.2200
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
31 51.500000 3539.2500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 31 51.500000 3539.2500 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 2 3.500000 233.2500 233.2500
8 14.500000 1087.5000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 10 18.000000 1320.7500 233.2500
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 3 6.000000 450.0000 450.0000
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 20 39.226267 2891.9700 0.0000
T 0 0.000000 0.0000 0.0000
28 51.473601 3760.5200 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 51 96.699868 7102.4900 450.0000
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 1 4.000000 200.0000 200.0000
102 135.000000 9091.5000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 103 139.000000 9291.5000 200.0000