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: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 7 11.250000 416.2500 37.0000
Subtotal (Total Children Is Unduplicated) 7 11.250000 416.2500 37.0000
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 3 4.500000 337.5000 75.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 6 12.000000 900.0000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 3 6.000000 450.0000 75.0000
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 2 4.000000 300.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 1 1.500000 112.5000 75.0000
IPDEF-T1024TLTSGT-F/U PHYC AND DEV EVAL BY EI PROF 2 3.000000 225.0000 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 10 18.500000 1026.7500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 80 152.500000 11097.5000 72.7705
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 143 249.505600 18662.9200 74.7996
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 37 64.500000 4837.5000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 68 113.000000 8475.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 30 53.500000 3892.5000 72.7570
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 50 80.067867 6005.0900 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 46 76.500000 4245.7500 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 139 233.000000 12681.5000 54.4270
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 28 46.935500 3520.1625 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 46 71.000000 5325.0000 75.0000
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 8 8.000000 2199.8800 274.9850
Subtotal (Total Children Is Unduplicated) 403 1200.008967 84405.5525 70.3374
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 1 4.000000 200.0000 50.0000
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 1 1.000000 71.4400 71.4400
Subtotal (Total Children Is Unduplicated) 2 5.000000 271.4400 54.2880
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Total 1216.258967 85093.2425 69.9631
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Number of Children (Unduplicated) With at Least One Service 405
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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 32 48.500000 3286.5000 3286.5000
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 11 16.500000 1110.7500 0.0000
T 0 0.000000 0.0000 0.0000
38 44.000000 2684.5000 0.0000
Other 2 3.000000 225.0000 0.0000
---------------------------------------------------------
Total 83 112.000000 7306.7500 3286.5000
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 7 11.000000 825.0000 825.0000
3 5.500000 412.5000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 10 16.500000 1237.5000 825.0000
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
58 97.500000 7308.9400 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 58 97.500000 7308.9400 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
19 18.000000 2949.8800 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 19 18.000000 2949.8800 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 3.000000 195.7500 195.7500
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
94 140.000000 9681.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 96 143.000000 9876.7500 195.7500
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 14 26.935500 2020.1625 2020.1600
D 1 2.000000 150.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 2 4.000000 300.0000 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 24 46.935500 3520.1625 2020.1600
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 40 72.500000 4748.7500 4765.4600
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
37 65.500000 4269.0000 0.0000
Other 13 26.000000 1950.0000 0.0000
---------------------------------------------------------
Total 90 164.000000 10967.7500 4765.4600
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
73 134.500000 9161.2500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 73 134.500000 9161.2500 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 8 16.000000 930.1400 644.7700
D 5 10.000000 633.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 13 25.000000 1680.0000 0.0000
T 16 32.000000 1975.8600 1815.8600
19 31.500000 2127.5000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 61 114.500000 7346.5000 2460.6300
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 2 1.250000 46.2500 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
27 44.500000 3054.7500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 29 45.750000 3101.0000 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 0 0.000000 0.0000 0.0000
S 1 1.500000 112.5000 0.0000
H 0 0.000000 0.0000 0.0000
T 4 7.500000 494.2500 494.2500
35 57.000000 3914.2500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 40 66.000000 4521.0000 494.2500
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 3 6.000000 450.0000 450.0000
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 6 12.000000 900.0000 0.0000
T 0 0.000000 0.0000 0.0000
46 78.073467 5816.5100 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 55 96.073467 7166.5100 450.0000
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 0 0.000000 0.0000 0.0000
94 160.500000 10554.2500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 94 160.500000 10554.2500 0.0000