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: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 1 1.500000 55.5000 37.0000
Subtotal (Total Children Is Unduplicated) 1 1.500000 55.5000 37.0000
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Screening, Eval, and Assessment,Class #02
EVAL-96111-DEVELOPMENTAL EVALUATION 1 2.000000 100.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 1 1.000000 55.5000 55.5000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 3 6.000000 450.0000 75.0000
IPDEF-T1024TLTSGT-F/U PHYC AND DEV EVAL BY EI PROF 1 2.000000 150.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 1 1.000000 55.5000 55.5000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 4 8.000000 444.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 43 80.000000 5830.0000 72.8750
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 154 255.652801 19105.7100 74.7330
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 18 30.000000 2250.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 53 84.064133 6254.8100 74.4052
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 14 24.500000 1837.5000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 48 77.000000 5775.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 30 58.000000 2955.0000 50.9483
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 171 282.500000 15244.0000 53.9611
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 15 29.000000 2175.0000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 39 58.500000 4387.5000 75.0000
MED-99201-OUTPATIENT VISIT, NEW, 10 MINS 1 1.000000 103.0000 103.0000
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 6 6.000000 1824.0000 304.0000
Subtotal (Total Children Is Unduplicated) 359 1006.216934 68996.5200 68.5702
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EI Services,Class #03
DSTT-DSTT-DIRECT SERVICE COORDINATOR TRAVEL 1 1.000000 0.0000 0.0000
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 1 3.559910 254.3200 71.4400
Subtotal (Total Children Is Unduplicated) 2 4.559910 254.3200 55.7730
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Total 1012.276844 69306.3400 68.4658
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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 16 25.500000 1483.5000 1483.5000
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 7 9.500000 683.2500 0.0000
T 7 10.500000 641.2500 641.2500
12 17.000000 1177.5000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 42 62.500000 3985.5000 2124.7500
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 2 3.500000 262.5000 262.5000
0 0.000000 0.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 2 3.500000 262.5000 262.5000
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
43 74.500000 5587.5000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 43 74.500000 5587.5000 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 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
26 29.500000 3614.5000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 26 29.500000 3614.5000 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 8 12.000000 783.0000 783.0000
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
112 155.000000 10572.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 120 167.000000 11355.0000 783.0000
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 0 0.000000 0.0000 0.0000
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 2 4.000000 300.0000 0.0000
T 0 0.000000 0.0000 0.0000
14 27.000000 1677.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 16 31.000000 1977.0000 0.0000
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 35 64.000000 3739.5000 4096.0000
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 4 5.000000 187.2500 0.0000
27 45.500000 2847.0000 0.0000
Other 19 35.500000 2467.5000 0.0000
---------------------------------------------------------
Total 85 150.000000 9241.2500 4096.0000
Center 10
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 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
50 93.500000 6417.7500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 50 93.500000 6417.7500 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 9 17.500000 816.1200 666.8100
D 12 24.000000 1410.0000 0.0000
S 1 2.000000 150.0000 0.0000
H 23 45.000000 3141.0000 0.0000
T 26 52.000000 3294.1300 2749.1300
9 17.000000 1099.5000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 80 157.500000 9910.7500 3415.9400
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
28 49.500000 3207.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 28 49.500000 3207.0000 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 4 8.000000 561.0000 561.0000
14 26.500000 1870.5000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 18 34.500000 2431.5000 561.0000
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 5 9.000000 671.4400 671.4400
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 19 38.000000 2800.0000 0.0000
T 0 0.000000 0.0000 0.0000
32 47.276844 3536.6500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 56 94.276844 7008.0900 671.4400
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 4 4.500000 288.7500 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
49 60.500000 4019.2500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 53 65.000000 4308.0000 0.0000