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:TPIN
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 37 60.750000 2247.7500 37.0000
Subtotal (Total Children Is Unduplicated) 38 61.250000 2266.2500 37.0000
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Screening, Eval, and Assessment,Class #02
ASTE-ASTE-ASSISTIVE TECHNOLOGY EVAL 2 2.000000 97.0000 48.5000
EVAL-96111-DEVELOPMENTAL EVALUATION 1 1.000000 50.0000 50.0000
EVAL-96111GT-DEVELOPMENTAL EVALUATION 2 2.500000 125.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 6 9.500000 712.5000 75.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 15 26.500000 1948.5000 73.5283
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 4 7.000000 525.0000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 1 2.000000 150.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 3 6.500000 487.5000 75.0000
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 3 5.000000 375.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 2 3.500000 262.5000 75.0000
IPDEF-T1024TLTSGT-F/U PHYC AND DEV EVAL BY EI PROF 7 10.000000 750.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 8 13.000000 804.7500 61.9038
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 9 14.000000 777.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 129 263.500000 19422.5000 73.7097
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 404 776.500000 57857.3000 74.5104
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 54 108.000000 8100.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 173 335.500000 25152.5000 74.9702
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 45 90.000000 6750.0000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 120 224.000000 16837.5000 75.1674
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 89 183.500000 10184.2500 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 335 649.500000 35668.0500 54.9162
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 57 114.697700 8573.0775 74.7450
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 158 259.422200 19456.6650 75.0000
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 11 11.000000 3344.0000 304.0000
OCTH-97165-OT EVAL LOW COMPLEXITY 1 1.000000 51.0500 51.0500
OCTH-97165GT-OT EVAL LOW COMPLEXITY 3 3.000000 153.1500 51.0500
OCTH-97166-OT EVAL MODERATE COMPLEXITY 1 1.000000 51.0500 51.0500
OCTH-97166GT-OT EVAL MODERATE COMPLEXITY 1 1.000000 1.0500 1.0500
OCTH-97166TLGT-OT EVAL MODERATE COMPLEXITY 1 1.000000 51.0500 51.0500
OCTH-97167TLGT-OT EVAL HIGH COMPLEXITY 1 1.000000 51.0500 51.0500
PSTF-97164-PT RE-EVAL EST PLAN CARE 1 1.000000 51.0500 51.0500
PSTH-97161-PT EVAL LOW COMPLEXITY 1 1.000000 51.0500 51.0500
PSTH-97161GT-PT EVAL LOW COMPLEXITY 1 1.000000 51.0500 51.0500
PSTH-97163-PT EVAL HIGH COMPLEXITY 2 2.000000 102.1000 51.0500
SCREEN-T1023-SCREENING 9 9.000000 450.0000 50.0000
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 20 20.000000 1021.0000 51.0500
SPCH-92523GT-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 4 4.000000 204.2000 51.0500
SPCH-92523TLGT-EVAL OF SPCH SOUND PROD; EVAL LANG COM 1 1.000000 51.0500 51.0500
Subtotal (Total Children Is Unduplicated) 991 3165.119900 220750.4925 69.7447
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EI Services,Class #03
DSTT-DSTT-DIRECT SERVICE COORDINATOR TRAVEL 2 2.000000 0.0000 0.0000
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 1 2.000000 50.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 68 311.000000 15290.0000 49.1640
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 67 241.000000 12050.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 25 40.000000 2857.6000 71.4400
OCCT-97530GT-OT SESSION BY LICENSED OT 65 249.250000 17806.4200 71.4400
OCCT-97530TLGT-OT SESSION BY LICENSED OT 6 37.000000 2582.5500 69.7986
PHY-97110-PT SESSION BY LICENSED PT 35 112.500000 8037.0000 71.4400
PHY-97110GT-PT SESSION BY LICENSED PT 31 115.250000 8314.4400 72.1426
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 122 500.750000 35331.8200 70.5578
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 87 310.000000 22106.7000 71.3119
SPL-92507TLGT-SPL THERAPY SESSION BY LICENSED SLP 8 52.000000 3714.8800 71.4400
SPL-92508-GROUP SPL SESSION PER CHILD 2 2.000000 27.7600 13.8800
Subtotal (Total Children Is Unduplicated) 445 1974.750000 128169.1700 64.9040
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Total 5201.119900 351185.9125 67.5212
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Number of Children (Unduplicated) With at Least One Service 1367
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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 2 1.250000 80.6900 0.0000
H 140 167.500000 10907.6400 0.0000
T 0 0.000000 0.0000 0.0000
64 56.000000 3336.8600 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 206 224.750000 14325.1900 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 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
597 739.750000 53297.3000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 597 739.750000 53297.3000 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
100 121.000000 11408.7500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 100 121.000000 11408.7500 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
1 0.500000 18.5000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 1 0.500000 18.5000 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
192 339.000000 23367.7500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 192 339.000000 23367.7500 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 6 6.119900 458.9925 458.9800
D 7 14.000000 1050.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 13 26.000000 1950.0000 0.0000
T 0 0.000000 0.0000 0.0000
58 112.250000 7869.2500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 84 158.369900 11328.2425 458.9800
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 130 177.000000 11635.3300 11882.6000
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 9 15.500000 984.3800 35.7200
97 143.500000 9601.6900 47.8600
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 236 336.000000 22221.4000 11966.1800
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
422 938.000000 64329.7500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 422 938.000000 64329.7500 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
12 28.750000 1866.3000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 12 28.750000 1866.3000 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 59 77.000000 3804.2500 2874.9100
D 82 97.500000 5173.5000 0.0000
S 5 5.000000 357.2000 0.0000
H 160 215.500000 14242.4200 115.0000
T 200 237.500000 14259.5800 10331.5300
86 118.000000 6902.3700 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 592 750.500000 44739.3200 13321.4400
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 2 1.750000 206.0000 206.0000
D 3 2.500000 178.6000 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
588 680.750000 42325.0300 0.0000
Other 34 34.000000 2343.2000 0.0000
---------------------------------------------------------
Total 627 719.000000 45052.8300 206.0000
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 3 3.000000 214.3200 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
388 422.750000 29934.7200 0.0000
Other 36 35.500000 2343.1600 0.0000
---------------------------------------------------------
Total 427 461.250000 32492.2000 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 0 0.000000 0.0000 0.0000
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 68 99.000000 7212.4500 0.0000
T 0 0.000000 0.0000 0.0000
36 51.000000 3750.2400 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 104 150.000000 10962.6900 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 1 1.000000 50.0000 50.0000
162 233.250000 15725.6900 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 163 234.250000 15775.6900 50.0000