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:OTHER
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 82 140.250000 5189.2500 37.0000
Subtotal (Total Children Is Unduplicated) 82 140.250000 5189.2500 37.0000
-----------------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
EVAL-96111GT-DEVELOPMENTAL EVALUATION 1 2.000000 100.0000 50.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 4 6.500000 487.5000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 1 1.500000 112.5000 75.0000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 2 3.000000 166.5000 55.5000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 26 44.500000 3337.5000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 36 61.000000 4575.0000 75.0000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 55 93.500000 5189.2500 55.5000
Subtotal (Total Children Is Unduplicated) 68 212.000000 13968.2500 65.8880
-----------------------------------------------------------------------------------------------------------------------
EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 1 4.000000 200.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 1 2.000000 100.0000 50.0000
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 1 1.000000 71.4400 71.4400
Subtotal (Total Children Is Unduplicated) 3 7.000000 371.4400 53.0629
-----------------------------------------------------------------------------------------------------------------------
Total 359.250000 19528.9400 54.3603
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 95
-----------------------------------------------------------------------------------------------------------------------
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 2 2.000000 100.0000 100.0000
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 171 286.500000 16015.7500 0.0000
T 0 0.000000 0.0000 0.0000
9 8.500000 314.5000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 182 297.000000 16430.2500 100.0000
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 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
31 35.000000 2090.4400 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 31 35.000000 2090.4400 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 0 0.000000 0.0000 0.0000
27 27.250000 1008.2500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 27 27.250000 1008.2500 0.0000