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: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 1 0.500000 18.5000 37.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 14 22.000000 814.0000 37.0000
Subtotal (Total Children Is Unduplicated) 15 22.500000 832.5000 37.0000
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Screening, Eval, and Assessment,Class #02
EXIT-EXIT-EXIT ASSESSMENT 8 10.000000 500.0000 50.0000
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 9 17.500000 1312.5000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 3 5.000000 375.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 2 4.000000 300.0000 75.0000
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 3 6.000000 400.0000 66.6667
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 1 2.000000 150.0000 75.0000
IPDEF-T1024TLTSGT-F/U PHYC AND DEV EVAL BY EI PROF 5 9.000000 675.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 1 2.000000 111.0000 55.5000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 12 21.500000 1093.2500 50.8488
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 161 324.201400 23257.6050 71.7381
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 297 550.503500 40691.1825 73.9163
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 63 130.000000 9285.0000 71.4231
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 92 167.500000 12233.1900 73.0340
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 62 116.000000 8530.0000 73.5345
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 72 125.000000 9375.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 105 212.000000 11634.0000 54.8774
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 246 454.500000 24444.0000 53.7822
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 72 142.500000 10687.5000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 123 250.500000 18787.5000 75.0000
MED-99202-OUTPATIENT VISIT, NEW, 20 MINS 1 1.000000 304.0000 304.0000
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 11 11.000000 2866.7900 260.6173
OCTH-97165-OT EVAL LOW COMPLEXITY 4 4.000000 204.2000 51.0500
OCTH-97165GT-OT EVAL LOW COMPLEXITY 1 1.000000 51.0500 51.0500
OCTH-97166-OT EVAL MODERATE COMPLEXITY 2 2.000000 102.1000 51.0500
OCTH-97167-OT EVAL HIGH COMPLEXITY 1 1.000000 51.0500 51.0500
PSTF-97164-PT RE-EVAL EST PLAN CARE 1 1.000000 51.0500 51.0500
PSTF-97164GT-PT RE-EVAL EST PLAN CARE 1 1.000000 51.0500 51.0500
PSTH-97161-PT EVAL LOW COMPLEXITY 3 3.000000 173.5400 57.8467
PSTH-97162-PT EVAL MODERATE COMPLEXITY 1 1.000000 51.0500 51.0500
SCREEN-T1023-SCREENING 5 5.000000 250.0000 50.0000
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 12 12.000000 632.9900 52.7492
SPCH-92524-BEHAV & QUAL ANALYSIS OF VOICE AND RES 1 1.000000 51.0500 51.0500
Subtotal (Total Children Is Unduplicated) 857 2601.204900 179244.1475 68.9081
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EI Services,Class #03
DSTT-DSTT-DIRECT SERVICE COORDINATOR TRAVEL 2 2.250000 0.0000 0.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 92 412.000000 20575.0000 49.9393
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 51 168.250000 8412.5000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 35 107.000000 7438.3200 69.5170
OCCT-97530GT-OT SESSION BY LICENSED OT 53 174.000000 12466.2800 71.6453
OCCT-97530TL-OT SESSION BY LICENSED OT 1 1.000000 71.4400 71.4400
OCCT-97530TLGT-OT SESSION BY LICENSED OT 4 5.000000 357.2000 71.4400
PHY-97110-PT SESSION BY LICENSED PT 45 136.750000 9769.4200 71.4400
PHY-97110GT-PT SESSION BY LICENSED PT 29 87.000000 6215.2800 71.4400
PHY-97110TL-PT SESSION BY LICENSED PT 1 1.000000 71.4400 71.4400
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 154 620.500000 41699.8500 67.2036
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 85 339.500000 24113.4400 71.0263
SPL-92507TL-SPL THERAPY SESSION BY LICENSED SLP 1 4.000000 285.7600 71.4400
SPL-92507TLGT-SPL THERAPY SESSION BY LICENSED SLP 1 0.750000 53.5800 71.4400
Subtotal (Total Children Is Unduplicated) 452 2059.000000 131529.5100 63.8803
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Total 4682.704900 311606.1575 66.5441
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Number of Children (Unduplicated) With at Least One Service 1226
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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 0 0.000000 0.0000 0.0000
S 1 2.000000 150.0000 0.0000
H 157 189.750000 12161.3100 0.0000
T 0 0.000000 0.0000 0.0000
24 25.250000 1798.4400 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 182 217.000000 14109.7500 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
470 582.500000 42182.0400 0.0000
Other 8 14.000000 1050.0000 0.0000
---------------------------------------------------------
Total 478 596.500000 43232.0400 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
77 143.500000 13033.2900 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 77 143.500000 13033.2900 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 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
192 341.000000 23430.0000 0.0000
Other 1 0.750000 27.7500 0.0000
---------------------------------------------------------
Total 193 341.750000 23457.7500 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 2 1.704900 127.8675 127.8600
D 3 6.000000 450.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 5 10.000000 750.0000 0.0000
T 0 0.000000 0.0000 0.0000
46 90.750000 6777.7500 0.0000
Other 1 0.500000 18.5000 0.0000
---------------------------------------------------------
Total 57 108.954900 8124.1175 127.8600
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 51 87.500000 4725.7000 5091.0100
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 1 1.500000 33.2500 0.0000
56 95.000000 6090.4100 0.0000
Other 1 2.000000 111.0000 0.0000
---------------------------------------------------------
Total 109 186.000000 10960.3600 5091.0100
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 3 1.500000 107.1600 107.1600
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
318 658.000000 45195.2900 0.0000
Other 2 2.500000 158.2500 0.0000
---------------------------------------------------------
Total 323 662.000000 45460.7000 107.1600
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
20 38.500000 2543.3200 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 20 38.500000 2543.3200 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 126 156.500000 8422.0100 6167.9900
D 200 215.500000 10965.0000 130.0000
S 1 2.000000 150.0000 130.0000
H 161 205.000000 13001.3200 35.0000
T 257 298.750000 16544.3400 11968.6500
15 24.000000 1062.7600 0.0000
Other 1 0.500000 18.5000 0.0000
---------------------------------------------------------
Total 761 902.250000 50163.9300 18431.6400
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 12 14.000000 953.6400 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
503 512.250000 34126.3000 0.0000
Other 70 70.000000 5017.4800 0.0000
---------------------------------------------------------
Total 585 596.250000 40097.4200 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 2 2.000000 121.4400 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
391 427.250000 29824.8200 0.0000
Other 41 42.000000 2814.6400 0.0000
---------------------------------------------------------
Total 434 471.250000 32760.9000 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 91 124.000000 8866.9800 0.0000
T 0 0.000000 0.0000 0.0000
53 55.250000 3887.9300 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 144 179.250000 12754.9100 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 3 5.000000 345.7500 623.7900
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 34 57.500000 2632.4200 0.0000
101 177.000000 11929.5000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 138 239.500000 14907.6700 623.7900