CMS/EIP Fiscal Report Statewide
Services beginning 10/01/2022 ending 12/31/2022 Date of Report:01/23/2023 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 758 3082.500000 114546.4000 37.1602
Subtotal (Total Children Is Unduplicated) 758 3082.500000 114546.4000 37.1602
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 10 19.500000 1462.5000 75.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 7 11.000000 825.0000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 12 22.000000 1650.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 6 11.500000 862.5000 75.0000
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 3 5.500000 412.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 4 8.000000 600.0000 75.0000
IPDEF-T1024TLTSGT-F/U PHYC AND DEV EVAL BY EI PROF 4 7.500000 562.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 3 5.500000 305.2500 55.5000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 19 35.000000 1942.5000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 91 172.500000 12937.5000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 155 258.333333 19375.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 23 37.500000 2812.5000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 97 158.000000 11850.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 26 45.500000 3375.0000 74.1758
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 68 111.500000 8362.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 106 192.500000 10683.7500 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 268 447.000000 24808.5000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 37 61.000000 4575.0000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 70 128.000000 9600.0000 75.0000
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 3 3.000000 228.4500 76.1500
SPCH-92523GT-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 1 1.000000 51.4100 51.4100
Subtotal (Total Children Is Unduplicated) 542 1741.333333 117282.3600 67.3520
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 3 12.000000 600.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 1 4.000000 287.8400 71.9600
Subtotal (Total Children Is Unduplicated) 4 16.000000 887.8400 55.4900
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Total 4839.833333 232716.6000 48.0836
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Number of Children (Unduplicated) With at Least One Service 795
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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 185 158.000000 7459.8000 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 21 24.750000 1634.1000 0.0000
---------------------------------------------------------
Total 206 182.750000 9093.9000 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 123 101.750000 4645.5000 0.0000
---------------------------------------------------------
Total 123 101.750000 4645.5000 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 70 98.250000 3997.1500 0.0000
P 4 6.000000 259.8000 259.8000
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 2.000000 150.0000 0.0000
Other 33 36.750000 1422.0000 0.0000
---------------------------------------------------------
Total 108 143.000000 5828.9500 259.8000
Center 04
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 4 6.000000 298.8000 0.0000
U 0 0.000000 0.0000 0.0000
B 126 196.750000 8252.1000 0.0000
P 48 81.000000 3433.9500 3375.7500
D 2 1.250000 46.5000 0.0000
S 0 0.000000 0.0000 0.0000
H 3 8.000000 487.8400 0.0000
T 0 0.000000 0.0000 0.0000
48 52.500000 3211.9500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 231 345.500000 15731.1400 3375.7500
Center 05
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 204 186.000000 6912.5000 3352.1600
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 204 186.000000 6912.5000 3352.1600
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
319 397.000000 19222.7000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 319 397.000000 19222.7000 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 48 56.500000 2891.4000 0.0000
P 83 112.000000 5582.2500 5582.2500
D 0 0.000000 0.0000 0.0000
S 3 1.250000 46.5000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
2 1.000000 37.2000 0.0000
Other 6 6.250000 232.5000 0.0000
---------------------------------------------------------
Total 142 177.000000 8789.8500 5582.2500
Center 09
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 1 2.000000 111.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 66 100.000000 4652.2000 166.8000
P 80 133.500000 5985.3500 5872.5500
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 2887.5000 0.0000
Other 28 52.000000 3568.5000 0.0000
---------------------------------------------------------
Total 195 326.000000 17204.5500 6039.3500
Center 10
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 384 486.500000 24001.2500 0.0000
P 0 0.000000 0.0000 0.0000
D 8 12.500000 672.9000 0.0000
S 4 7.250000 269.7000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
2 4.000000 261.0000 0.0000
Other 5 6.500000 241.8000 0.0000
---------------------------------------------------------
Total 403 516.750000 25446.6500 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 1 1.500000 112.5000 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
3 3.000000 181.9100 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 4 4.500000 294.4100 0.0000
Center 52
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 2 4.000000 261.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 40 58.750000 3123.9500 0.0000
P 38 56.750000 2898.7000 2897.9000
D 0 0.000000 0.0000 0.0000
S 21 15.750000 585.9000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
5 8.500000 579.6000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 106 143.750000 7449.1500 2897.9000
Center 53
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 4 4.250000 158.1000 0.0000
U 0 0.000000 0.0000 0.0000
B 66 62.250000 3094.0000 0.0000
P 180 186.000000 8970.7000 8966.2000
D 10 9.000000 398.8500 0.0000
S 3 3.500000 130.2000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
36 42.750000 2109.3000 0.0000
Other 5 6.000000 223.0500 0.0000
---------------------------------------------------------
Total 304 313.750000 15084.2000 8966.2000
Center 54
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 7 9.000000 542.7000 0.0000
U 0 0.000000 0.0000 0.0000
B 94 130.500000 6358.0500 37.2000
P 387 462.250000 20450.3000 20441.7000
D 14 18.750000 1093.2000 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
72 118.750000 6443.5000 0.0000
Other 4 5.250000 251.2500 138.7500
---------------------------------------------------------
Total 578 744.500000 35139.0000 20617.6500
Center 55
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 149 258.500000 13454.4000 0.0000
P 68 105.250000 5078.2000 5078.2000
D 0 0.000000 0.0000 0.0000
S 1 1.333333 100.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
47 94.000000 6348.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 265 459.083333 24980.6000 5078.2000
Center 57
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 14 36.750000 1367.1000 0.0000
U 0 0.000000 0.0000 0.0000
B 276 566.750000 25866.5500 0.0000
P 91 170.000000 8570.7500 8570.1500
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 17.000000 689.1000 596.6600
2 8.000000 400.0000 400.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 390 798.500000 36893.5000 9566.8100