CMS/EIP Fiscal Report Statewide
Services beginning 01/01/2023 ending 03/31/2023 Date of Report:04/20/2023 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
Screening, Eval, and Assessment,Class #02
EVAL-96111-DEVELOPMENTAL EVALUATION 2 4.000000 200.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 5 9.500000 712.5000 75.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 3 4.500000 337.5000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 3 6.000000 450.0000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 3 4.500000 337.5000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 2.000000 150.0000 75.0000
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 1 2.000000 150.0000 75.0000
IPDEF-T1024TLTSGT-F/U PHYC AND DEV EVAL BY EI PROF 2 3.500000 262.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 4 7.500000 416.2500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 89 167.525599 12261.9200 73.1943
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 123 214.500000 16062.2500 74.8823
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 24 44.500000 3237.5000 72.7528
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 57 96.000000 7200.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 13 27.500000 1902.5000 69.1818
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 60 100.000000 7500.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 64 110.500000 6132.7500 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 165 284.000000 15762.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 40 58.500000 4387.5000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 44 84.500000 6337.5000 75.0000
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 4 4.000000 1216.0000 304.0000
Subtotal (Total Children Is Unduplicated) 400 1235.025599 85016.1700 68.8376
-----------------------------------------------------------------------------------------------------------------------
EI Services,Class #03
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 1 2.000000 100.0000 50.0000
Subtotal (Total Children Is Unduplicated) 1 2.000000 100.0000 50.0000
-----------------------------------------------------------------------------------------------------------------------
Total 1237.025599 85116.1700 68.8071
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 401
-----------------------------------------------------------------------------------------------------------------------
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 1 1.500000 112.5000 112.5000
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 18 27.000000 1908.0000 0.0000
T 6 8.000000 502.5000 502.5000
22 31.500000 2284.5000 0.0000
Other 11 16.500000 1091.2500 0.0000
---------------------------------------------------------
Total 58 84.500000 5898.7500 615.0000
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 19.000000 1425.0000 1425.0000
0 0.000000 0.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 11 19.000000 1425.0000 1425.0000
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
11 17.500000 1126.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 11 17.500000 1126.0000 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
28 31.500000 3210.2500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 28 31.500000 3210.2500 0.0000
Center 05
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 1.500000 112.5000 112.5000
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
0 0.000000 0.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 1 1.500000 112.5000 112.5000
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 2 3.000000 225.0000 225.0000
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
78 118.000000 8099.2500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 80 121.000000 8324.2500 225.0000
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 5 10.000000 750.0000 750.0000
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 1 2.000000 150.0000 0.0000
T 0 0.000000 0.0000 0.0000
8 16.000000 1200.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 14 28.000000 2100.0000 750.0000
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 15 28.500000 2079.0000 2079.0000
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
41 76.500000 4821.0000 0.0000
Other 16 32.000000 2400.0000 0.0000
---------------------------------------------------------
Total 72 137.000000 9300.0000 2079.0000
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
132 232.000000 15585.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 132 232.000000 15585.0000 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 0 0.000000 0.0000 0.0000
P 9 18.000000 1114.0000 826.6300
D 13 26.000000 1599.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 18 35.000000 2283.7500 0.0000
T 23 45.500000 2836.5000 2636.5000
11 22.000000 1472.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 74 146.500000 9305.2500 3463.1300
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
32 56.500000 3789.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 32 56.500000 3789.0000 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 0 0.000000 0.0000 0.0000
H 1 2.000000 150.0000 0.0000
T 3 5.000000 277.5000 277.5000
49 87.500000 6084.7500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 53 94.500000 6512.2500 277.5000
Center 55
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 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 21 42.000000 3100.0000 0.0000
T 0 0.000000 0.0000 0.0000
19 34.525599 2539.4200 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 43 82.525599 6089.4200 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 2 3.000000 195.7500 341.1200
D 1 1.500000 112.5000 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
110 180.500000 12030.2500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 113 185.000000 12338.5000 341.1200