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
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 12211 36379.25000 1345184.5000 36.9767
Subtotal (Total Children Is Unduplicated) 12211 36379.25000 1345184.5000 36.9767
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 15 28.500000 2137.5000 75.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 39 69.500000 5173.5000 74.4388
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 7 13.500000 1012.5000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 26 40.000000 3000.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 6 11.500000 862.5000 75.0000
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 11 19.500000 1462.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 10 19.500000 1462.5000 75.0000
IPDEF-T1024TLTSGT-F/U PHYC AND DEV EVAL BY EI PROF 16 29.000000 2145.7500 73.9914
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 23 42.000000 2331.0000 55.5000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 46 78.000000 4329.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 272 513.500000 38512.5000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 693 1199.500000 89933.2500 74.9756
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 89 164.000000 12300.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 354 542.000000 40597.5000 74.9031
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 111 207.000000 15525.0000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 177 307.000000 23025.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 349 636.500000 35325.7500 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 902 1533.500000 85109.2500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 133 236.000000 17700.0000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 243 411.000000 30790.5000 74.9161
MED-99201-OUTPATIENT VISIT, NEW, 10 MINS 2 2.000000 60.7000 30.3500
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 24 24.000000 1556.5100 64.8546
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 3 3.000000 78.0100 26.0033
OCTH-97165TL-OT EVAL LOW COMPLEXITY 2 2.000000 102.1000 51.0500
OCTH-97165TLGT-OT EVAL LOW COMPLEXITY 1 1.000000 51.0500 51.0500
OCTH-97166TLGT-OT EVAL MODERATE COMPLEXITY 2 2.000000 102.1000 51.0500
OCTH-97167-OT EVAL HIGH COMPLEXITY 2 2.000000 102.1000 51.0500
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-97162TL-PT EVAL MODERATE COMPLEXITY 2 2.000000 102.1000 51.0500
SCREEN-T1023-SCREENING 19 19.000000 950.0000 50.0000
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 4 4.000000 204.2000 51.0500
SPCH-92523GT-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 1 1.000000 51.0500 51.0500
SPCH-92523TL-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 9 9.000000 459.4500 51.0500
SPCH-92523TLGT-EVAL OF SPCH SOUND PROD; EVAL LANG COM 3 3.000000 146.6500 48.8833
SPCH-92610-EVAL OF ORAL,PHARYNGEAL SWALLOWING FUNC 1 1.000000 44.5500 44.5500
Subtotal (Total Children Is Unduplicated) 2007 6178.000000 416848.1700 67.4730
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 226 921.500000 46075.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 411 1252.500000 62625.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 13 26.000000 1857.4400 71.4400
OCCT-97530GT-OT SESSION BY LICENSED OT 12 16.250000 1160.9000 71.4400
OCCT-97530TL-OT SESSION BY LICENSED OT 31 72.500000 5179.4000 71.4400
OCCT-97530TLGT-OT SESSION BY LICENSED OT 89 275.750000 19699.5800 71.4400
PHY-97110-PT SESSION BY LICENSED PT 15 34.000000 2428.9600 71.4400
PHY-97110GT-PT SESSION BY LICENSED PT 5 11.000000 785.8400 71.4400
PHY-97110TL-PT SESSION BY LICENSED PT 75 222.250000 15877.5400 71.4400
PHY-97110TLGT-PT SESSION BY LICENSED PT 51 144.000000 10287.3600 71.4400
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 42 116.750000 8340.6200 71.4400
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 8 15.000000 1071.6000 71.4400
SPL-92507TL-SPL THERAPY SESSION BY LICENSED SLP 98 354.250000 25307.6200 71.4400
SPL-92507TLGT-SPL THERAPY SESSION BY LICENSED SLP 120 488.250000 34694.0600 71.0580
SPL-92508TLGT-SPL THERAPY SESSION BY LICENSED SLP 2 2.000000 27.7600 13.8800
Subtotal (Total Children Is Unduplicated) 1003 3952.000000 235418.6800 59.5695
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Total 46509.250000 1997451.3500 42.9474
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Number of Children (Unduplicated) With at Least One Service 12599
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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 1 0.500000 18.5000 0.0000
P 0 0.000000 0.0000 0.0000
D 0 0.000000 0.0000 0.0000
S 711 560.750000 31533.2200 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
1 2.250000 83.2500 0.0000
Other 1 0.250000 9.2500 0.0000
---------------------------------------------------------
Total 714 563.750000 31644.2200 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 1458 998.750000 42484.7500 0.0000
---------------------------------------------------------
Total 1458 998.750000 42484.7500 0.0000
Center 03
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 67 35.000000 1295.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 1725 1598.500000 80643.9000 0.0000
P 0 0.000000 0.0000 0.0000
D 2 2.000000 100.0000 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
22 24.000000 1682.9300 0.0000
Other 1406 916.250000 36707.1500 0.0000
---------------------------------------------------------
Total 3222 2575.750000 120428.9800 0.0000
Center 04
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 13 24.500000 906.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 2613 4335.500000 172628.5000 0.0000
P 737 1234.250000 48738.7500 48470.4700
D 9 9.000000 333.0000 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
180 228.250000 14161.2200 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 3552 5831.500000 236767.9700 48470.4700
Center 05
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 11 9.000000 333.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 2348 1541.000000 57017.0000 24341.3800
P 0 0.000000 0.0000 0.0000
D 1 0.500000 18.5000 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
26 12.000000 444.0000 0.0000
Other 30 23.000000 851.0000 0.0000
---------------------------------------------------------
Total 2416 1585.500000 58663.5000 24341.3800
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
4643 3562.750000 151062.2500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 4643 3562.750000 151062.2500 0.0000
Center 07
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 4 2.000000 74.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 375 302.500000 11944.5000 0.0000
P 2475 2081.500000 88536.0000 88268.0000
D 2 2.500000 129.5000 0.0000
S 3 4.500000 318.5000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
14 9.500000 351.5000 0.0000
Other 299 172.250000 6673.2500 0.0000
---------------------------------------------------------
Total 3172 2574.750000 108027.2500 88268.0000
Center 09
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 368 401.000000 16178.5700 166.5000
P 3765 3893.250000 153489.1200 153695.6220
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 5 6.000000 277.5000 527.2500
3 3.000000 142.9200 0.0000
Other 8 10.250000 379.2500 0.0000
---------------------------------------------------------
Total 4149 4313.500000 170467.3600 154389.3720
Center 10
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 73 55.750000 2062.7500 0.0000
U 0 0.000000 0.0000 0.0000
B 8661 7459.250000 308249.7500 0.0000
P 67 92.250000 5470.7500 0.0000
D 28 21.500000 956.2500 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 401 296.000000 11424.0000 0.0000
---------------------------------------------------------
Total 9230 7924.750000 328163.5000 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 23 30.000000 2045.2500 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
67 105.000000 6459.1600 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 90 135.000000 8504.4100 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 601 616.250000 27850.7200 252.1000
P 1753 1888.250000 88466.6500 93254.4800
D 2 3.250000 120.2500 0.0000
S 18 21.250000 975.3200 101.7500
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
16 15.250000 564.2500 0.0000
Other 14 9.750000 360.7500 0.0000
---------------------------------------------------------
Total 2404 2554.000000 118337.9400 93608.3300
Center 53
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 34 31.750000 1588.0300 0.0000
U 0 0.000000 0.0000 0.0000
B 1937 1766.250000 87334.6900 1055.0000
P 1312 1254.500000 59858.8900 59840.3900
D 46 46.250000 3311.2200 0.0000
S 144 116.000000 6764.4800 1554.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
226 213.750000 9614.9100 0.0000
Other 148 115.750000 5977.5800 0.0000
---------------------------------------------------------
Total 3847 3544.250000 174449.8000 62449.3900
Center 54
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 3 4.250000 157.2500 0.0000
U 0 0.000000 0.0000 0.0000
B 3179 2678.000000 123228.4500 1959.2500
P 1644 1437.750000 66788.8100 66669.8400
D 14 13.750000 810.7800 0.0000
S 8 6.500000 240.5000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
76 76.500000 3298.3400 0.0000
Other 134 102.500000 4739.5800 0.0000
---------------------------------------------------------
Total 5058 4319.250000 199263.7100 68629.0900
Center 55
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 1 2.000000 150.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 2731 2180.500000 90573.4600 0.0000
P 4 7.750000 286.7500 286.7500
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
0 0.000000 0.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 2736 2190.250000 91010.2100 286.7500
Center 57
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 1 0.500000 18.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 725 955.500000 40454.7500 0.0000
P 2072 2771.750000 113867.5000 113939.1500
D 0 0.000000 0.0000 0.0000
S 1 1.500000 112.5000 0.0000
H 0 0.000000 0.0000 0.0000
T 34 104.000000 3639.0000 2577.9500
1 0.500000 18.5000 0.0000
Other 2 1.750000 64.7500 0.0000
---------------------------------------------------------
Total 2836 3835.500000 158175.5000 116517.1000