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: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 2.000000 74.0000 37.0000
Subtotal (Total Children Is Unduplicated) 1 2.000000 74.0000 37.0000
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 4 7.500000 562.5000 75.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 1 1.500000 83.2500 55.5000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 2 3.000000 225.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 3 3.233733 242.5300 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 2 3.500000 262.5000 75.0000
IPDEF-T1024TLTSGT-F/U PHYC AND DEV EVAL BY EI PROF 4 5.000000 375.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 2 3.500000 194.2500 55.5000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 3 4.000000 222.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 55 111.500000 7702.5000 69.0807
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 133 216.200000 15985.0000 73.9362
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 12 22.500000 1687.5000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 63 101.700000 7377.5000 72.5418
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 19 34.500000 2587.5000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 48 78.000000 5750.0000 73.7179
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 41 78.000000 4218.0000 54.0769
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 162 257.000000 13946.0300 54.2647
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 18 31.169100 2337.6825 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 37 58.500000 4337.5000 74.1453
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 4 4.000000 1216.0000 304.0000
Subtotal (Total Children Is Unduplicated) 355 1024.302833 69312.2425 67.6677
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 1 14.000000 700.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 1 7.000000 500.0800 71.4400
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 1 6.500000 464.3600 71.4400
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 1 1.000000 71.4400 71.4400
Subtotal (Total Children Is Unduplicated) 3 28.500000 1735.8800 60.9081
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Total 1054.802833 71122.1225 67.4269
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Number of Children (Unduplicated) With at Least One Service 357
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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 21 27.000000 1674.0000 1674.0000
D 5 7.000000 492.1900 0.0000
S 0 0.000000 0.0000 0.0000
H 9 13.000000 887.2500 0.0000
T 0 0.000000 0.0000 0.0000
5 8.000000 502.5000 0.0000
Other 1 1.500000 112.5000 0.0000
---------------------------------------------------------
Total 41 56.500000 3668.4400 1674.0000
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 8 14.500000 990.0000 990.0000
1 2.000000 150.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 9 16.500000 1140.0000 990.0000
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
39 63.500000 4762.5000 0.0000
Other 5 7.500000 562.5000 0.0000
---------------------------------------------------------
Total 44 71.000000 5325.0000 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
15 16.500000 2153.5000 0.0000
Other 4 13.500000 964.4400 0.0000
---------------------------------------------------------
Total 19 30.000000 3117.9400 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 13 17.000000 1167.7500 1167.7500
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
111 164.000000 11120.2500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 124 181.000000 12288.0000 1167.7500
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 11 21.169100 1548.6825 1548.6800
D 1 2.000000 150.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 1 2.000000 150.0000 0.0000
T 0 0.000000 0.0000 0.0000
6 12.000000 900.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 19 37.169100 2748.6825 1548.6800
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 33 60.500000 3740.5000 3806.5400
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 4.000000 300.0000 300.0000
33 58.500000 3646.5000 0.0000
Other 1 2.000000 150.0000 0.0000
---------------------------------------------------------
Total 69 125.000000 7837.0000 4106.5400
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
49 87.000000 6037.5000 0.0000
Other 4 9.000000 636.0000 0.0000
---------------------------------------------------------
Total 53 96.000000 6673.5000 0.0000
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
2 2.000000 130.5000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 2 2.000000 130.5000 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 7 14.000000 795.5900 592.5500
D 11 22.000000 1260.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 18 36.000000 2505.0000 0.0000
T 27 54.000000 3371.4100 2969.4100
15 30.000000 1601.0000 53.6100
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 78 156.000000 9533.0000 3615.5700
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
19 29.000000 1814.2500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 19 29.000000 1814.2500 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 2 3.100000 172.0000 172.0000
28 46.400000 3365.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 30 49.500000 3537.0000 172.0000
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 7 14.000000 1050.0000 1050.0000
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 11 22.000000 1650.0000 0.0000
T 0 0.000000 0.0000 0.0000
12 18.633733 1397.5300 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 30 54.633733 4097.5300 1050.0000
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 195.7500 312.4600
D 2 2.000000 130.5000 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 17 38.000000 1797.5300 700.0000
72 107.500000 7087.5000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 93 150.500000 9211.2800 1012.4600