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: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 3 9.500000 351.5000 37.0000
Subtotal (Total Children Is Unduplicated) 3 9.500000 351.5000 37.0000
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 2 3.500000 262.5000 75.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 3 6.000000 450.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 2.000000 150.0000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 1 2.000000 150.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 1.500000 112.5000 75.0000
IPDEF-T1024TLTSGT-F/U PHYC AND DEV EVAL BY EI PROF 2 4.000000 300.0000 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 3 5.500000 305.2500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 42 74.000000 5550.0000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 123 214.000000 16000.0000 74.7664
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 10 18.000000 1350.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 54 85.128266 6384.6200 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 19 36.000000 2530.0000 70.2778
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 47 75.833333 5658.2500 74.6143
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 33 61.500000 3413.2500 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 126 214.500000 11879.7500 55.3834
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 22 40.500000 3037.5000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 55 80.500000 6037.5000 75.0000
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 9 9.000000 2736.0000 304.0000
Subtotal (Total Children Is Unduplicated) 327 935.461599 66418.1200 71.0004
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EI Services,Class #03
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 1 1.000000 50.0000 50.0000
Subtotal (Total Children Is Unduplicated) 1 1.000000 50.0000 50.0000
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Total 945.961599 66819.6200 70.6367
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Number of Children (Unduplicated) With at Least One Service 328
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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 10 15.000000 959.2500 959.2500
D 3 5.500000 412.5000 0.0000
S 0 0.000000 0.0000 0.0000
H 5 6.000000 391.5000 0.0000
T 14 21.500000 1407.7500 1407.7500
11 15.500000 1133.2500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 43 63.500000 4304.2500 2367.0000
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 11 21.000000 1458.0000 1458.0000
0 0.000000 0.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 11 21.000000 1458.0000 1458.0000
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
31 43.000000 3225.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 31 43.000000 3225.0000 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
27 28.000000 4161.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 27 28.000000 4161.0000 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 2 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
102 148.000000 10271.2500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 104 150.000000 10421.2500 150.0000
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 1 2.000000 150.0000 150.0000
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 3 6.000000 450.0000 0.0000
T 0 0.000000 0.0000 0.0000
7 14.000000 1050.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 11 22.000000 1650.0000 150.0000
Center 09
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 0 0.000000 0.0000 0.0000
P 21 38.000000 2382.0000 2423.3600
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 2.000000 111.0000 0.0000
32 57.000000 3690.0000 0.0000
Other 18 34.000000 2550.0000 0.0000
---------------------------------------------------------
Total 72 131.000000 8733.0000 2423.3600
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
58 118.000000 8011.5000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 58 118.000000 8011.5000 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
1 1.500000 112.5000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 1 1.500000 112.5000 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 3 6.000000 241.0000 188.6500
D 6 12.000000 666.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 4 8.000000 600.0000 37.5000
T 7 13.000000 975.0000 875.0000
17 34.000000 2355.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 37 73.000000 4837.0000 1101.1500
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
16 24.250000 1504.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 16 24.250000 1504.0000 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 8 7.750000 362.7500 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
11 19.250000 1269.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 21 31.000000 1931.7500 300.0000
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 4 8.000000 600.0000 600.0000
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 21 42.000000 3150.0000 0.0000
T 0 0.000000 0.0000 0.0000
14 21.711599 1618.8700 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 39 71.711599 5368.8700 600.0000
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 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 1 1.500000 83.2500 0.0000
99 166.500000 11018.2500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 100 168.000000 11101.5000 0.0000