CMS/EIP Fiscal Report Statewide
Services beginning 04/01/2022 ending 06/30/2022 Date of Report:08/08/2022 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 946 3876.750000 143282.5000 36.9594
Subtotal (Total Children Is Unduplicated) 946 3876.750000 143282.5000 36.9594
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 9 16.000000 1200.0000 75.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 15 28.000000 2100.0000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 4 6.000000 450.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 4 7.000000 525.0000 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 3 5.000000 375.0000 75.0000
IPDEF-T1024TLTSGT-F/U PHYC AND DEV EVAL BY EI PROF 4 9.500000 712.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 7 11.500000 638.2500 55.5000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 18 32.000000 1776.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 99 176.000000 13200.0000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 228 387.127467 29034.5600 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 33 53.000000 3975.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 125 202.000000 15150.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 44 72.000000 5400.0000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 91 148.500000 11108.2500 74.8030
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 129 223.500000 12404.2500 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 345 575.500000 31940.2500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 41 67.000000 5025.0000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 68 109.500000 8212.5000 75.0000
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 8 8.000000 575.0400 71.8800
SCREEN-T1023-SCREENING 2 2.000000 100.0000 50.0000
Subtotal (Total Children Is Unduplicated) 664 2158.627467 145364.1000 67.3410
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 2 22.000000 1100.0000 50.0000
Subtotal (Total Children Is Unduplicated) 2 22.000000 1100.0000 50.0000
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Total 6057.377467 289746.6000 47.8337
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Number of Children (Unduplicated) With at Least One Service 971
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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 77 76.250000 4239.2500 0.0000
H 212 198.000000 8618.7500 8618.7500
T 0 0.000000 0.0000 0.0000
0 0.000000 0.0000 0.0000
Other 50 60.750000 3977.0000 0.0000
---------------------------------------------------------
Total 339 335.000000 16835.0000 8618.7500
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 197 175.500000 7363.2500 0.0000
---------------------------------------------------------
Total 197 175.500000 7363.2500 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 152 198.500000 9533.7500 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
0 0.000000 0.0000 0.0000
Other 84 100.750000 4751.2500 0.0000
---------------------------------------------------------
Total 236 299.250000 14285.0000 0.0000
Center 04
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 3 3.000000 205.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 75 94.750000 4432.1500 0.0000
P 94 153.750000 6312.7500 6309.7900
D 14 23.500000 1009.7500 0.0000
S 0 0.000000 0.0000 0.0000
H 3 12.000000 600.0000 0.0000
T 0 0.000000 0.0000 0.0000
24 27.250000 1726.1400 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 213 314.250000 14286.2900 6309.7900
Center 05
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 227 205.750000 7612.7500 5272.5000
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 2 0.750000 27.7500 0.0000
---------------------------------------------------------
Total 229 206.500000 7640.5000 5272.5000
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
304 348.000000 16576.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 304 348.000000 16576.0000 0.0000
Center 07
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 1 2.000000 74.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 48 71.250000 3773.2500 0.0000
P 160 158.750000 7207.7500 7207.7500
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 4 2.000000 74.0000 0.0000
---------------------------------------------------------
Total 213 234.000000 11129.0000 7207.7500
Center 09
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 65 99.750000 5110.5000 0.0000
P 120 185.500000 7915.5000 7915.5000
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 26.000000 1950.0000 0.0000
Other 37 66.000000 4511.2500 0.0000
---------------------------------------------------------
Total 236 377.250000 19487.2500 7915.5000
Center 10
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 26 25.750000 1254.7500 0.0000
U 0 0.000000 0.0000 0.0000
B 466 518.250000 24089.0000 0.0000
P 2 3.000000 195.7500 0.0000
D 1 2.000000 150.0000 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 45 59.750000 2816.2500 0.0000
---------------------------------------------------------
Total 540 608.750000 28505.7500 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 10.000000 500.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 2 10.000000 500.0000 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 23 30.000000 1677.0000 0.0000
P 88 128.250000 5981.5000 5938.8300
D 0 0.000000 0.0000 0.0000
S 33 40.750000 1902.2500 177.7300
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
9 18.000000 1233.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 153 217.000000 10793.7500 6116.5600
Center 53
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 6 11.000000 786.0000 0.0000
P 47 55.750000 3215.2500 3215.2500
D 2 1.000000 37.0000 0.0000
S 30 21.500000 795.5000 0.0000
H 6 7.000000 316.0000 0.0000
T 0 0.000000 0.0000 0.0000
378 443.250000 20408.2500 0.0000
Other 4 5.000000 268.2500 0.0000
---------------------------------------------------------
Total 473 544.500000 25826.2500 3215.2500
Center 54
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 1 2.000000 150.0000 0.0000
P 85 114.500000 6817.5000 6817.5000
D 2 1.750000 121.7500 0.0000
S 6 9.500000 712.5000 0.0000
H 1 1.500000 112.5000 0.0000
T 0 0.000000 0.0000 0.0000
655 774.750000 35536.2500 0.0000
Other 14 13.000000 481.0000 0.0000
---------------------------------------------------------
Total 764 917.000000 43931.5000 6817.5000
Center 55
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 140 259.500000 14326.5000 0.0000
P 188 272.250000 12499.2500 11420.0800
D 0 0.000000 0.0000 0.0000
S 1 0.627467 47.0600 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
56 110.000000 7606.5000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 385 642.377467 34479.3100 11420.0800
Center 57
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 201 359.750000 17214.7500 0.0000
P 237 448.250000 19830.0000 19829.6300
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 6 11.250000 511.2500 425.5000
3 6.000000 450.0000 0.0000
Other 1 2.750000 101.7500 0.0000
---------------------------------------------------------
Total 448 828.000000 38107.7500 20255.1300