CMS/EIP Fiscal Report Statewide
Services beginning 10/01/2021 ending 12/31/2021 Date of Report:02/04/2022 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 831 3376.250000 124627.5000 36.9130
Subtotal (Total Children Is Unduplicated) 831 3376.250000 124627.5000 36.9130
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 3 6.000000 450.0000 75.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 18 32.000000 2400.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 1.500000 112.5000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 11 19.000000 1425.0000 75.0000
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 6 10.000000 750.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 2 4.000000 300.0000 75.0000
IPDEF-T1024TLTSGT-F/U PHYC AND DEV EVAL BY EI PROF 5 9.500000 712.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 9 17.000000 943.5000 55.5000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 19 34.000000 1887.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 56 95.000000 7125.0000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 259 441.000000 33006.7500 74.8452
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 13 22.500000 1687.5000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 117 180.500000 13537.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 28 47.500000 3562.5000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 95 165.500000 12412.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 88 155.000000 8493.0000 54.7935
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 316 512.000000 28416.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 43 75.000000 5625.0000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 92 156.000000 11670.7500 74.8125
MED-99201-OUTPATIENT VISIT, NEW, 10 MINS 2 2.000000 60.7000 30.3500
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 6 6.000000 379.4000 63.2333
Subtotal (Total Children Is Unduplicated) 618 1991.000000 134957.1000 67.7836
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EI Services,Class #03
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 1 5.000000 250.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 1 4.000000 285.7600 71.4400
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 1 2.000000 142.8800 71.4400
Subtotal (Total Children Is Unduplicated) 2 11.000000 678.6400 61.6945
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Total 5378.250000 260263.2400 48.3918
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Number of Children (Unduplicated) With at Least One Service 900
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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 2 2.500000 158.2500 0.0000
S 44 53.750000 3493.0000 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 21 31.500000 2011.5000 0.0000
---------------------------------------------------------
Total 67 87.750000 5662.7500 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 215 178.500000 8153.0000 0.0000
---------------------------------------------------------
Total 215 178.500000 8153.0000 0.0000
Center 03
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 1 2.000000 74.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 139 207.500000 10990.5000 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
2 3.000000 225.0000 0.0000
Other 74 96.000000 4450.7500 0.0000
---------------------------------------------------------
Total 216 308.500000 15740.2500 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 131 209.750000 9015.0000 0.0000
P 56 85.250000 3692.5000 3692.8900
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
33 35.500000 2239.3500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 220 330.500000 14946.8500 3692.8900
Center 05
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 197 194.250000 7187.2500 2747.2500
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 197 194.250000 7187.2500 2747.2500
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
560 632.250000 31191.5000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 560 632.250000 31191.5000 0.0000
Center 07
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 8 9.500000 464.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 24 33.750000 1437.7500 0.0000
P 233 286.750000 13147.2500 13147.2500
D 0 0.000000 0.0000 0.0000
S 1 2.000000 150.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
2 0.750000 27.7500 0.0000
Other 20 18.500000 684.5000 0.0000
---------------------------------------------------------
Total 288 351.250000 15911.7500 13147.2500
Center 09
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 9 14.250000 789.2500 0.0000
P 140 223.500000 9959.7500 9959.7500
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
28 52.000000 3900.0000 0.0000
Other 36 62.500000 4311.2500 0.0000
---------------------------------------------------------
Total 213 352.250000 18960.2500 9959.7500
Center 10
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 1 0.500000 18.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 368 416.500000 18893.7500 0.0000
P 9 15.500000 914.5000 1672.4000
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 26 21.250000 786.2500 0.0000
---------------------------------------------------------
Total 404 453.750000 20613.0000 1672.4000
Center 51
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 5 5.500000 393.0000 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
15 19.500000 1136.6400 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 20 25.000000 1529.6400 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 27 41.250000 1830.2500 0.0000
P 112 187.750000 9369.5000 9452.7500
D 0 0.000000 0.0000 0.0000
S 2 4.000000 261.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
8 16.000000 1044.0000 0.0000
Other 1 0.500000 18.5000 0.0000
---------------------------------------------------------
Total 150 249.500000 12523.2500 9452.7500
Center 53
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 114 126.250000 6023.7500 0.0000
P 128 147.000000 6621.7500 6621.7500
D 0 0.000000 0.0000 0.0000
S 4 3.000000 168.0000 18.5000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
15 21.250000 1094.0000 0.0000
Other 6 5.750000 212.7500 0.0000
---------------------------------------------------------
Total 267 303.250000 14120.2500 6640.2500
Center 54
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 297 334.750000 15447.5000 150.0000
P 109 140.750000 6645.7500 6645.7500
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
35 51.750000 3061.2500 0.0000
Other 3 3.000000 148.0000 0.0000
---------------------------------------------------------
Total 445 532.250000 25452.5000 6795.7500
Center 55
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 475 596.500000 28181.5000 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
110 220.000000 14862.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 585 816.500000 43043.5000 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 55 96.250000 4619.5000 0.0000
P 231 450.000000 19997.5000 20043.7500
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 2 8.250000 305.2500 259.0000
0 0.000000 0.0000 0.0000
Other 4 8.250000 305.2500 0.0000
---------------------------------------------------------
Total 292 562.750000 25227.5000 20302.7500