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
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 12926 38961.50000 1441090.0000 36.9875
Subtotal (Total Children Is Unduplicated) 12926 38961.50000 1441090.0000 36.9875
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 13 25.500000 1912.5000 75.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 36 58.500000 4320.7500 73.8590
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 2 3.500000 262.5000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 18 26.500000 1950.0000 73.5849
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 4 7.500000 562.5000 75.0000
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 7 10.500000 787.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 4 8.000000 600.0000 75.0000
IPDEF-T1024TLTSGT-F/U PHYC AND DEV EVAL BY EI PROF 19 32.500000 2408.2500 74.1000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 27 47.500000 2636.2500 55.5000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 45 68.500000 3801.7500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 277 512.000000 38350.0000 74.9023
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 868 1501.500000 112563.7500 74.9675
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 114 212.000000 15900.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 299 490.000000 36750.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 114 213.000000 15975.0000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 198 355.500000 26662.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 356 668.500000 37101.7500 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 941 1582.500000 87801.0000 55.4825
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 160 290.000000 21750.0000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 266 435.000000 32625.0000 75.0000
MED-99201-OUTPATIENT VISIT, NEW, 10 MINS 5 5.000000 151.7500 30.3500
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 8 8.000000 471.2800 58.9100
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 1 1.000000 23.4200 23.4200
OCTH-97165TL-OT EVAL LOW COMPLEXITY 1 1.000000 51.0500 51.0500
OCTH-97165TLGT-OT EVAL LOW COMPLEXITY 2 2.000000 102.1000 51.0500
OCTH-97166-OT EVAL MODERATE COMPLEXITY 1 1.000000 51.0500 51.0500
OCTH-97166TL-OT EVAL MODERATE COMPLEXITY 1 1.000000 51.0500 51.0500
PSTH-97161-PT EVAL LOW COMPLEXITY 2 2.000000 102.1000 51.0500
PSTH-97161TL-PT EVAL LOW COMPLEXITY 1 1.000000 51.0500 51.0500
PSTH-97162TL-PT EVAL MODERATE COMPLEXITY 1 1.000000 51.0500 51.0500
PSTH-97163-PT EVAL HIGH COMPLEXITY 1 1.000000 51.0500 51.0500
SCREEN-T1023-SCREENING 16 16.000000 800.0000 50.0000
SPCH-92522GT-EVAL OF SPCH SOUND PROD 1 1.000000 51.0500 51.0500
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 10 11.000000 561.5500 51.0500
SPCH-92523TLGT-EVAL OF SPCH SOUND PROD; EVAL LANG COM 3 3.000000 153.1500 51.0500
Subtotal (Total Children Is Unduplicated) 2242 6605.500000 447545.8000 67.7535
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EI Services,Class #03
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 2 2.000000 50.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 236 866.750000 43337.5000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 411 1443.750000 72187.5000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 17 38.750000 2768.3000 71.4400
OCCT-97530GT-OT SESSION BY LICENSED OT 9 15.500000 1107.3200 71.4400
OCCT-97530TL-OT SESSION BY LICENSED OT 33 77.000000 5483.0200 71.2081
OCCT-97530TLGT-OT SESSION BY LICENSED OT 93 273.250000 19520.9800 71.4400
PHY-97110-PT SESSION BY LICENSED PT 25 47.750000 3411.2600 71.4400
PHY-97110GT-PT SESSION BY LICENSED PT 5 7.500000 535.8000 71.4400
PHY-97110TL-PT SESSION BY LICENSED PT 44 124.000000 8858.5600 71.4400
PHY-97110TLGT-PT SESSION BY LICENSED PT 71 221.000000 15788.2400 71.4400
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 35 128.750000 9197.9000 71.4400
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 8 13.500000 964.4400 71.4400
SPL-92507TL-SPL THERAPY SESSION BY LICENSED SLP 97 345.250000 24664.6600 71.4400
SPL-92507TLGT-SPL THERAPY SESSION BY LICENSED SLP 150 547.250000 38923.3000 71.1253
Subtotal (Total Children Is Unduplicated) 1016 4152.000000 246798.7800 59.4409
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Total 49719.000000 2135434.5800 42.9501
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Number of Children (Unduplicated) With at Least One Service 13416
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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 1015 910.000000 55787.4900 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
1 0.250000 9.2500 0.0000
Other 1 0.250000 9.2500 0.0000
---------------------------------------------------------
Total 1017 910.500000 55805.9900 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 1329 961.250000 41341.2500 0.0000
---------------------------------------------------------
Total 1329 961.250000 41341.2500 0.0000
Center 03
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 3 0.750000 27.7500 0.0000
U 0 0.000000 0.0000 0.0000
B 2547 2092.500000 100760.4700 0.0000
P 1 1.000000 71.4400 71.4400
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
39 35.500000 2487.8800 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 2590 2129.750000 103347.5400 71.4400
Center 04
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 2086 3367.000000 131550.5000 0.0000
P 829 1468.750000 57792.5000 57448.5700
D 7 10.000000 370.0000 0.0000
S 2 3.750000 138.7500 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
303 445.000000 22205.9500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 3227 5294.500000 212057.7000 57448.5700
Center 05
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 2643 1800.750000 68077.4600 33295.5700
P 0 0.000000 0.0000 0.0000
D 4 3.500000 232.8200 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
6 2.000000 74.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 2653 1806.250000 68384.2800 33295.5700
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
5902 4365.000000 180261.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 5902 4365.000000 180261.0000 0.0000
Center 07
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 63 45.000000 1665.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 850 679.750000 28881.7500 0.0000
P 2637 2335.500000 100378.7500 100149.3500
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
11 6.000000 222.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 3561 3066.250000 131147.5000 100149.3500
Center 09
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 1 1.250000 46.2500 0.0000
U 0 0.000000 0.0000 0.0000
B 748 764.250000 29974.6300 0.0000
P 3333 3482.500000 138386.1200 138336.1200
D 2 3.250000 120.2500 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 4 2.000000 74.0000 98.0500
2 2.000000 85.7600 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 4090 4255.250000 168687.0100 138434.1700
Center 10
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 13 12.000000 444.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 8791 7896.500000 334130.7500 0.0000
P 4 6.500000 468.5000 116.2000
D 180 165.750000 7922.0000 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 8988 8080.750000 342965.2500 116.2000
Center 51
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 19 22.000000 1445.2500 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
297 318.500000 14984.8500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 316 340.500000 16430.1000 0.0000
Center 52
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 1 0.500000 18.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 608 658.500000 32451.0300 0.0000
P 2224 2192.750000 95522.4000 94812.6600
D 1 2.000000 150.0000 0.0000
S 136 121.500000 5447.9000 131.0500
H 4 5.000000 300.0000 0.0000
T 0 0.000000 0.0000 0.0000
22 22.250000 880.7500 0.0000
Other 1 0.250000 9.2500 0.0000
---------------------------------------------------------
Total 2997 3002.750000 134779.8300 94943.7100
Center 53
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 31 31.000000 1550.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 2275 2031.250000 97916.9400 74.0000
P 1655 1458.750000 69454.4100 69097.2100
D 65 65.000000 4468.4200 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
200 189.000000 9016.1900 0.0000
Other 66 60.500000 3332.4100 0.0000
---------------------------------------------------------
Total 4292 3835.500000 185738.3700 69171.2100
Center 54
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 2824 2409.500000 106940.2600 0.0000
P 2447 2031.500000 89889.8900 89818.4520
D 14 13.500000 713.9400 0.0000
S 0 0.000000 0.0000 0.0000
H 1 1.000000 71.4400 0.0000
T 0 0.000000 0.0000 0.0000
223 216.250000 10540.6700 0.0000
Other 64 55.500000 3065.5200 0.0000
---------------------------------------------------------
Total 5573 4727.250000 211221.7200 89818.4520
Center 55
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 3706 2867.000000 117935.7900 0.0000
P 2 0.500000 18.5000 18.5000
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
41 40.500000 2025.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 3749 2908.000000 119979.2900 18.5000
Center 57
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 4 11.000000 407.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 2887 3755.500000 151364.7500 0.0000
P 215 262.250000 11266.2500 11099.7500
D 0 0.000000 0.0000 0.0000
S 1 0.500000 18.5000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
5 6.250000 231.2500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 3112 4035.500000 163287.7500 11099.7500