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
Agency Filter:EIP DEI DEIP
Payclass Filters:MED
Eligibility Filter:Part C (excluding not eligible)
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 13876 41112.25000 1520560.7500 36.9856
Subtotal (Total Children Is Unduplicated) 13876 41112.25000 1520560.7500 36.9856
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 24 43.000000 3186.0000 74.0930
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 60 104.000000 7683.0000 73.8750
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 4 8.000000 600.0000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 34 57.500000 4312.5000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 9 16.500000 1237.5000 75.0000
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 11 18.000000 1350.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 16 29.000000 2175.0000 75.0000
IPDEF-T1024TLTSGT-F/U PHYC AND DEV EVAL BY EI PROF 22 34.500000 2587.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 28 46.000000 2553.0000 55.5000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 51 83.500000 4634.2500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 224 414.000000 31050.0000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 876 1538.000000 115281.7500 74.9556
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 96 178.000000 13239.5000 74.3792
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 426 689.000000 51625.0000 74.9274
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 95 183.500000 13762.5000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 235 414.500000 31012.5000 74.8191
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 313 589.500000 32636.0000 55.3622
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 980 1643.000000 91149.5000 55.4775
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 143 266.000000 19950.0000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 329 549.000000 41175.0000 75.0000
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 24 24.000000 1413.8400 58.9100
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 1 1.000000 23.4200 23.4200
OCTH-97165TLGT-OT EVAL LOW COMPLEXITY 1 1.000000 51.0500 51.0500
PSTF-97164-PT RE-EVAL EST PLAN CARE 2 2.000000 102.1000 51.0500
PSTF-97164TL-PT RE-EVAL EST PLAN CARE 2 2.000000 102.1000 51.0500
PSTH-97161TL-PT EVAL LOW COMPLEXITY 3 3.000000 153.1500 51.0500
SCREEN-T1023-SCREENING 11 11.000000 550.0000 50.0000
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 2 2.000000 102.1000 51.0500
SPCH-92523TL-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 11 11.000000 561.5500 51.0500
SPCH-92523TLGT-EVAL OF SPCH SOUND PROD; EVAL LANG COM 2 2.000000 102.1000 51.0500
Subtotal (Total Children Is Unduplicated) 2281 6963.500000 474361.9100 68.1212
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EI Services,Class #03
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 2 3.000000 75.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 228 826.750000 41337.5000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 488 1701.000000 85000.0000 49.9706
OCCT-97530-OT SESSION BY LICENSED OT 14 26.000000 1857.4400 71.4400
OCCT-97530GT-OT SESSION BY LICENSED OT 21 56.000000 4000.6400 71.4400
OCCT-97530TL-OT SESSION BY LICENSED OT 24 50.250000 3589.8600 71.4400
OCCT-97530TLGT-OT SESSION BY LICENSED OT 106 349.500000 24968.2800 71.4400
PHY-97110-PT SESSION BY LICENSED PT 24 41.000000 2929.0400 71.4400
PHY-97110GT-PT SESSION BY LICENSED PT 4 5.750000 410.7800 71.4400
PHY-97110TL-PT SESSION BY LICENSED PT 44 122.000000 8715.6800 71.4400
PHY-97110TLGT-PT SESSION BY LICENSED PT 76 300.500000 21467.7200 71.4400
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 32 102.250000 7304.7400 71.4400
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 8 13.750000 982.3000 71.4400
SPL-92507TL-SPL THERAPY SESSION BY LICENSED SLP 74 288.250000 20592.5800 71.4400
SPL-92507TLGT-SPL THERAPY SESSION BY LICENSED SLP 128 513.750000 36644.7400 71.3280
Subtotal (Total Children Is Unduplicated) 1097 4399.750000 259876.3000 59.0662
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Total 52475.500000 2254798.9600 42.9686
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Number of Children (Unduplicated) With at Least One Service 14110
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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 2 0.500000 18.5000 0.0000
P 0 0.000000 0.0000 0.0000
D 2 2.000000 121.4400 0.0000
S 4449 2693.750000 118176.0300 0.0000
H 0 0.000000 0.0000 0.0000
T 1 0.500000 18.5000 0.0000
11 5.250000 194.2500 0.0000
Other 43 19.250000 825.2500 0.0000
---------------------------------------------------------
Total 4508 2721.250000 119353.9700 0.0000
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 0 0.000000 0.0000 0.0000
0 0.000000 0.0000 0.0000
Other 1178 922.750000 41682.2500 0.0000
---------------------------------------------------------
Total 1178 922.750000 41682.2500 0.0000
Center 03
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 158 122.250000 4746.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 2608 1919.000000 91256.1000 18.5000
P 110 99.250000 5086.7000 5086.7000
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
29 26.750000 1894.9400 0.0000
Other 13 8.250000 311.7500 0.0000
---------------------------------------------------------
Total 2918 2175.500000 103295.9900 5105.2000
Center 04
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 163 287.000000 11854.7500 0.0000
U 0 0.000000 0.0000 0.0000
B 404 597.000000 28425.0000 0.0000
P 621 1045.000000 44633.7500 44215.5400
D 24 37.250000 1955.5000 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
2173 3731.000000 143681.5100 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 3385 5697.250000 230550.5100 44215.5400
Center 05
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 242 162.750000 6021.7500 0.0000
U 0 0.000000 0.0000 0.0000
B 2661 1814.500000 69049.2700 36810.5700
P 0 0.000000 0.0000 0.0000
D 2 0.500000 18.5000 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 3.750000 138.7500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 2910 1981.500000 75228.2700 36810.5700
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
6409 4944.500000 207012.2500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 6409 4944.500000 207012.2500 0.0000
Center 07
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 312 221.000000 8177.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 649 534.000000 23563.7500 0.0000
P 2832 2368.000000 101433.5000 101461.2500
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 1 0.500000 18.5000 0.0000
T 0 0.000000 0.0000 0.0000
16 10.250000 455.2500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 3810 3133.750000 133648.0000 101461.2500
Center 09
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 285 283.500000 10593.2500 0.0000
U 0 0.000000 0.0000 0.0000
B 913 924.250000 35993.7500 0.0000
P 2857 3119.000000 124461.7500 124380.2700
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 300.0000
1 0.500000 18.5000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 4057 4329.250000 171217.2500 124680.2700
Center 10
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 291 253.500000 9727.2500 0.0000
U 0 0.000000 0.0000 0.0000
B 7834 6622.250000 277472.7500 0.0000
P 18 26.500000 1512.5000 669.5000
D 113 81.500000 3224.5000 0.0000
S 108 208.000000 14332.5000 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 8364 7191.750000 306269.5000 669.5000
Center 51
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 67 70.000000 4372.5000 0.0000
P 1 1.000000 55.5000 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
160 188.500000 8594.3600 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 228 259.500000 13022.3600 0.0000
Center 52
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 217 249.500000 14033.9000 0.0000
U 0 0.000000 0.0000 0.0000
B 1391 1322.500000 57648.7600 111.0000
P 1273 1214.000000 52760.5300 52154.9900
D 0 0.000000 0.0000 0.0000
S 267 236.250000 9971.0100 0.0000
H 0 0.000000 0.0000 0.0000
T 2 0.500000 18.5000 18.5000
113 110.500000 5228.7500 0.0000
Other 1 2.500000 92.5000 0.0000
---------------------------------------------------------
Total 3264 3135.750000 139753.9500 52284.4900
Center 53
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 2317 2083.500000 100236.3400 0.0000
U 0 0.000000 0.0000 0.0000
B 1562 1324.750000 64236.9300 0.0000
P 1093 993.500000 46791.0400 46791.0400
D 32 34.500000 2123.1800 0.0000
S 157 164.000000 10682.2600 0.0000
H 0 0.000000 0.0000 0.0000
T 1 2.000000 74.0000 0.0000
29 28.250000 1251.2500 0.0000
Other 14 14.750000 811.1700 0.0000
---------------------------------------------------------
Total 5205 4645.250000 226206.1700 46791.0400
Center 54
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 63 47.500000 2559.6400 0.0000
U 0 0.000000 0.0000 0.0000
B 1590 1317.750000 58537.8400 87.0000
P 1687 1453.000000 65553.3400 72251.7900
D 9 11.250000 804.5700 0.0000
S 14 16.750000 1214.7100 0.0000
H 1 0.250000 9.2500 9.2500
T 0 0.000000 0.0000 0.0000
2685 2329.250000 104955.6200 0.0000
Other 21 16.500000 1106.9000 69.2500
---------------------------------------------------------
Total 6070 5192.250000 234741.8700 72417.2900
Center 55
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 3800 3060.500000 126855.6200 0.0000
P 9 8.250000 305.2500 305.2500
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 52.500000 2033.5000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 3877 3121.250000 129194.3700 305.2500
Center 57
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 444 616.750000 22961.7500 0.0000
U 0 0.000000 0.0000 0.0000
B 578 749.250000 31452.0000 46.2500
P 1318 1616.250000 67493.2500 67020.0000
D 7 14.250000 527.2500 0.0000
S 0 0.000000 0.0000 0.0000
H 2 2.500000 187.5000 0.0000
T 1 1.250000 46.2500 46.2500
14 23.750000 954.2500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 2364 3024.000000 123622.2500 67112.5000