CMS/EIP Fiscal Report Statewide
Services beginning 01/01/2022 ending 03/31/2022 Date of Report:04/16/2022 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 736 3114.250000 115110.7000 36.9626
Subtotal (Total Children Is Unduplicated) 736 3114.250000 115110.7000 36.9626
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 1 2.000000 150.0000 75.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 17 31.000000 2325.0000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 7 13.500000 1012.5000 75.0000
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 10 18.500000 1387.5000 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 3 6.000000 450.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 3 5.000000 277.5000 55.5000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 18 30.500000 1692.7500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 39 68.000000 5100.0000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 261 435.000000 32566.5000 74.8655
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 16 28.000000 2100.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 144 236.000000 17622.0000 74.6695
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 20 35.000000 2625.0000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 106 175.000000 13095.7500 74.8329
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 81 146.000000 8103.0000 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 345 578.000000 32079.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 27 51.500000 3862.5000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 81 142.000000 10650.0000 75.0000
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 1 1.000000 71.8800 71.8800
Subtotal (Total Children Is Unduplicated) 631 2006.000000 135470.8800 67.5328
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Total 5120.250000 250581.5800 48.9393
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Number of Children (Unduplicated) With at Least One Service 803
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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 6 10.000000 594.0000 0.0000
S 59 74.500000 3888.5000 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 23 31.500000 2063.2500 0.0000
---------------------------------------------------------
Total 88 116.000000 6545.7500 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 205 176.250000 8219.2500 0.0000
---------------------------------------------------------
Total 205 176.250000 8219.2500 0.0000
Center 03
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 1 0.750000 27.7500 0.0000
U 0 0.000000 0.0000 0.0000
B 86 128.500000 7071.7500 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
1 1.500000 83.2500 0.0000
Other 4 6.500000 240.5000 0.0000
---------------------------------------------------------
Total 92 137.250000 7423.2500 0.0000
Center 04
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 1 1.000000 75.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 129 226.750000 9611.6300 0.0000
P 18 31.500000 1165.5000 1165.5000
D 2 3.750000 138.7500 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
16 19.500000 1239.2500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 166 282.500000 12230.1300 1165.5000
Center 05
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 5 5.750000 212.7500 0.0000
U 0 0.000000 0.0000 0.0000
B 178 158.500000 5864.5000 1951.7500
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 183 164.250000 6077.2500 1951.7500
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
482 564.000000 29001.7500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 482 564.000000 29001.7500 0.0000
Center 07
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 3 6.250000 231.2500 0.0000
U 0 0.000000 0.0000 0.0000
B 87 126.500000 6219.5000 0.0000
P 81 110.750000 5147.7500 5120.0000
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 171 243.500000 11598.5000 5120.0000
Center 09
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 40 63.250000 2983.5000 0.0000
P 178 276.500000 12662.7500 12662.7500
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
14 25.500000 1912.5000 0.0000
Other 52 93.250000 6538.2500 0.0000
---------------------------------------------------------
Total 284 458.500000 24097.0000 12662.7500
Center 10
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 274 334.250000 15793.5000 0.0000
P 1 2.250000 83.2500 16.6500
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 62 64.000000 2707.0000 0.0000
---------------------------------------------------------
Total 337 400.500000 18583.7500 16.6500
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
4 4.000000 261.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 4 4.000000 261.0000 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 13 18.750000 1110.7500 0.0000
P 63 101.500000 4813.5000 4813.5000
D 0 0.000000 0.0000 0.0000
S 4 4.500000 166.5000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
5 10.000000 633.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 85 134.750000 6723.7500 4813.5000
Center 53
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 163 192.750000 9204.5000 0.0000
P 85 107.000000 4683.7500 4683.7500
D 0 0.000000 0.0000 0.0000
S 2 3.500000 186.5000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
116 149.500000 7806.2500 0.0000
Other 25 19.000000 740.0000 0.0000
---------------------------------------------------------
Total 391 471.750000 22621.0000 4683.7500
Center 54
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 13 26.000000 1738.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 227 249.750000 10398.7500 0.0000
P 76 111.750000 5651.7500 5651.7500
D 0 0.000000 0.0000 0.0000
S 1 1.000000 75.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
225 285.750000 14661.5000 0.0000
Other 4 6.250000 268.2500 0.0000
---------------------------------------------------------
Total 546 680.500000 32793.2500 5651.7500
Center 55
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 396 563.500000 27639.0000 0.0000
P 1 2.000000 150.0000 150.0000
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
69 137.000000 9358.5000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 466 702.500000 37147.5000 150.0000
Center 57
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 112 214.250000 9352.5000 0.0000
P 197 356.750000 17383.2500 17383.2500
D 0 0.000000 0.0000 0.0000
S 1 1.500000 83.2500 83.2500
H 0 0.000000 0.0000 0.0000
T 2 3.750000 176.7500 20.3500
2 7.750000 262.7000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 314 584.000000 27258.4500 17486.8500