CMS/EIP Fiscal Report Statewide
Services beginning 07/01/2021 ending 09/30/2021 Date of Report:10/13/2021 Page: 1
List order: No List
Payclass Filters:MED
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 762 3442.000000 127354.0000 37.0000
Subtotal (Total Children Is Unduplicated) 762 3442.000000 127354.0000 37.0000
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 3 7.500000 562.5000 75.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 12 22.000000 1650.0000 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 8 14.500000 1087.5000 75.0000
IPDEF-T1024TLTSGT-F/U PHYC AND DEV EVAL BY EI PROF 2 3.000000 225.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 8 15.500000 860.2500 55.5000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 19 37.000000 2053.5000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 59 95.500000 7162.5000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 318 526.500000 39468.0000 74.9630
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 27 40.000000 3000.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 124 197.000000 14775.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 20 34.500000 2587.5000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 88 147.500000 11062.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 76 124.000000 6882.0000 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 372 598.500000 33216.7500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 31 53.000000 3975.0000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 89 158.000000 11850.0000 75.0000
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 2 2.000000 117.8200 58.9100
SCREEN-T1023-SCREENING 1 2.000000 100.0000 50.0000
Subtotal (Total Children Is Unduplicated) 666 2081.500000 140898.3200 67.6908
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 1 7.000000 350.0000 50.0000
Subtotal (Total Children Is Unduplicated) 1 7.000000 350.0000 50.0000
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Total 5530.500000 268602.3200 48.5675
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Number of Children (Unduplicated) With at Least One Service 853
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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 83 111.500000 7584.0000 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 51 76.000000 4822.5000 0.0000
---------------------------------------------------------
Total 134 187.500000 12406.5000 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 69 62.000000 2827.7500 0.0000
---------------------------------------------------------
Total 69 62.000000 2827.7500 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 164 200.750000 10056.5000 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 2.000000 111.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 165 202.750000 10167.5000 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 91 148.750000 6655.2500 0.0000
P 55 82.750000 3827.0000 3827.3300
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 33.750000 1998.8200 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 173 265.250000 12481.0700 3827.3300
Center 05
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 200 195.000000 7215.0000 3968.2500
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 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 200 195.000000 7215.0000 3968.2500
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
572 655.500000 32353.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 572 655.500000 32353.0000 0.0000
Center 07
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 5 4.500000 166.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 36 57.000000 2520.0000 0.0000
P 164 191.250000 8730.2500 8700.2500
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
0 0.000000 0.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 205 252.750000 11416.7500 8700.2500
Center 09
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 29 47.500000 2151.0000 0.0000
P 223 345.000000 15492.2500 15483.0000
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
19 35.500000 2662.5000 0.0000
Other 61 116.500000 8172.0000 0.0000
---------------------------------------------------------
Total 332 544.500000 28477.7500 15483.0000
Center 10
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 355 472.250000 22005.7500 0.0000
P 2 4.000000 300.0000 75.0000
D 6 11.250000 690.0000 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 7.000000 350.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 365 494.500000 23345.7500 75.0000
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
14 15.000000 903.2500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 14 15.000000 903.2500 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 22 36.500000 1991.5000 0.0000
P 111 171.250000 7987.0000 7987.4500
D 0 0.000000 0.0000 0.0000
S 4 5.250000 270.2500 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
5 8.750000 551.7500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 142 221.750000 10800.5000 7987.4500
Center 53
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 159 180.000000 8308.0000 0.0000
P 120 139.500000 7095.0000 7095.0000
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
24 39.000000 2231.5000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 303 358.500000 17634.5000 7095.0000
Center 54
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 219 257.500000 11520.5000 0.0000
P 147 190.500000 8752.5000 8752.5000
D 1 2.000000 150.0000 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
51 82.750000 4926.7500 0.0000
Other 1 2.000000 74.0000 0.0000
---------------------------------------------------------
Total 419 534.750000 25423.7500 8752.5000
Center 55
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 543 685.000000 32210.0000 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
83 166.000000 11007.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 626 851.000000 43217.0000 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 376 642.500000 27732.5000 0.0000
P 32 47.250000 2199.7500 2199.7500
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 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 408 689.750000 29932.2500 2199.7500