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: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 5 4.250000 157.2500 37.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 19 38.750000 1433.7500 37.0000
Subtotal (Total Children Is Unduplicated) 22 43.000000 1591.0000 37.0000
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Screening, Eval, and Assessment,Class #02
EVAL-96111-DEVELOPMENTAL EVALUATION 4 5.110800 255.5400 50.0000
EVAL-96111GT-DEVELOPMENTAL EVALUATION 1 2.000000 100.0000 50.0000
EXIT-EXIT-EXIT ASSESSMENT 7 9.110800 455.5400 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 9 18.000000 1350.0000 75.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 9 15.163200 1078.7400 71.1420
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 4 8.000000 600.0000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 3 4.000000 300.0000 75.0000
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 1 2.000000 150.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 4 8.500000 598.5000 70.4118
IPDEF-T1024TLTSGT-F/U PHYC AND DEV EVAL BY EI PROF 7 9.000000 675.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 7 13.000000 721.5000 55.5000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 12 21.500000 1193.2500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 158 323.500000 23412.5000 72.3725
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 351 661.886133 48854.8000 73.8115
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 68 129.500000 9372.5000 72.3745
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 101 197.000000 14176.0400 71.9596
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 95 183.000000 13555.0000 74.0710
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 96 176.500000 13227.5000 74.9433
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 112 235.500000 12674.0100 53.8175
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 291 537.000000 29288.3000 54.5406
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 70 142.000000 10650.0000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 100 155.500000 11662.5000 75.0000
MED-99201-OUTPATIENT VISIT, NEW, 10 MINS 2 2.000000 407.0000 203.5000
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 17 17.000000 4677.8200 275.1659
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 1 1.000000 193.0000 193.0000
OCTH-97165-OT EVAL LOW COMPLEXITY 3 3.000000 153.1500 51.0500
OCTH-97165GT-OT EVAL LOW COMPLEXITY 1 1.000000 51.0500 51.0500
OCTH-97166GT-OT EVAL MODERATE COMPLEXITY 1 1.000000 8.5500 8.5500
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
SCREEN-T1023-SCREENING 11 11.000000 550.0000 50.0000
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 10 11.000000 561.5500 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) 947 2911.770933 201361.7400 69.1544
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EI Services,Class #03
DSTT-DSTT-DIRECT SERVICE COORDINATOR TRAVEL 1 1.000000 0.0000 0.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 86 398.000000 19795.0000 49.7362
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 54 179.500000 8975.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 33 67.000000 4786.4800 71.4400
OCCT-97530GT-OT SESSION BY LICENSED OT 60 201.750000 14285.5200 70.8080
OCCT-97530TLGT-OT SESSION BY LICENSED OT 6 11.000000 785.8400 71.4400
PHY-97110-PT SESSION BY LICENSED PT 32 82.250000 5875.9400 71.4400
PHY-97110GT-PT SESSION BY LICENSED PT 31 137.750000 9840.8600 71.4400
PHY-97110TL-PT SESSION BY LICENSED PT 1 1.000000 71.4400 71.4400
PHY-97110TLGT-PT SESSION BY LICENSED PT 1 1.000000 71.4400 71.4400
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 122 503.500000 35680.6000 70.8651
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 96 352.250000 24806.8000 70.4238
SPL-92507TL-SPL THERAPY SESSION BY LICENSED SLP 1 3.000000 214.3200 71.4400
SPL-92507TLGT-SPL THERAPY SESSION BY LICENSED SLP 9 19.000000 1339.5000 70.5000
SPL-92508-GROUP SPL SESSION PER CHILD 1 1.000000 13.8800 13.8800
Subtotal (Total Children Is Unduplicated) 440 1959.000000 126542.6200 64.5955
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Total 4913.770933 329495.3600 67.0555
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Number of Children (Unduplicated) With at Least One Service 1307
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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 1 1.000000 50.0000 0.0000
S 1 1.000000 50.0000 0.0000
H 191 222.000000 13964.9900 0.0000
T 0 0.000000 0.0000 0.0000
43 46.500000 3165.8100 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 236 270.500000 17230.8000 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
477 613.500000 44633.3200 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 477 613.500000 44633.3200 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 1 1.000000 75.0000 92.5000
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
96 114.000000 12103.5700 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 97 115.000000 12178.5700 92.5000
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
188 329.500000 22518.7500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 188 329.500000 22518.7500 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 0 0.000000 0.0000 0.0000
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 27 54.000000 4050.0000 0.0000
T 0 0.000000 0.0000 0.0000
71 130.250000 8558.2500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 98 184.250000 12608.2500 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 77 116.000000 7458.8400 7814.4200
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 3 5.000000 189.5500 0.0000
70 120.500000 7521.8600 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 150 241.500000 15170.2500 7814.4200
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 1 2.500000 178.6000 178.6000
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 0 0.000000 0.0000 0.0000
360 781.500000 53708.2500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 361 784.000000 53886.8500 178.6000
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
35 77.500000 5322.1500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 35 77.500000 5322.1500 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 95 142.500000 7899.2100 6283.8500
D 131 150.250000 7849.5000 130.0000
S 2 3.000000 221.4400 112.5000
H 176 230.500000 15079.4000 328.9600
T 212 258.250000 13360.2000 9567.9800
61 67.000000 3451.3800 9.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 677 851.500000 47861.1300 16432.2900
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 2 4.000000 261.0000 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
582 632.750000 41613.4800 0.0000
Other 26 25.750000 1839.5800 0.0000
---------------------------------------------------------
Total 610 662.500000 43714.0600 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 1 1.000000 71.4400 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
328 353.500000 24610.4100 0.0000
Other 49 48.000000 3418.4000 0.0000
---------------------------------------------------------
Total 378 402.500000 28100.2500 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 89 123.548000 8752.4600 0.0000
T 0 0.000000 0.0000 0.0000
74 89.472933 6399.0200 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 163 213.020933 15151.4800 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 2 3.000000 120.7500 75.0000
D 6 6.500000 448.5000 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
114 159.000000 10550.2500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 122 168.500000 11119.5000 75.0000