CMS/EIP Fiscal Report Statewide
Services beginning 10/01/2023 ending 12/31/2023 Date of Report:01/14/2024 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 681 2796.000000 104020.5000 37.2033
Subtotal (Total Children Is Unduplicated) 681 2796.000000 104020.5000 37.2033
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 11 22.500000 1687.5000 75.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 2 4.000000 300.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 2 4.000000 300.0000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 2 3.500000 262.5000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 5 8.000000 600.0000 75.0000
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 3 6.000000 450.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 6 11.000000 825.0000 75.0000
IPDEF-T1024TLTSGT-F/U PHYC AND DEV EVAL BY EI PROF 1 1.500000 112.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 15 27.000000 1498.5000 55.5000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 8 13.500000 749.2500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 159 284.500000 21337.5000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 91 154.000000 11550.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 39 68.000000 5100.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 87 149.000000 11175.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 41 60.500000 4537.5000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 42 76.500000 5737.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 196 334.500000 18592.5000 55.5830
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 172 291.000000 16179.7500 55.6005
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 61 102.500000 7687.5000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 59 96.000000 7200.0000 75.0000
SPCH-92610TL-EVAL OF ORAL,PHARYNGEAL SWALLOWING FUNC 1 1.000000 51.4100 51.4100
Subtotal (Total Children Is Unduplicated) 578 1718.500000 115933.9100 67.4623
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 5 32.000000 1600.0000 50.0000
Subtotal (Total Children Is Unduplicated) 5 32.000000 1600.0000 50.0000
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Total 4546.500000 221554.4100 48.7308
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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 1 1.500000 112.5000 0.0000
S 0 0.000000 0.0000 0.0000
H 82 113.500000 7917.7500 7917.7500
T 0 0.000000 0.0000 0.0000
0 0.000000 0.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 83 115.000000 8030.2500 7917.7500
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 78 70.250000 3229.8000 0.0000
---------------------------------------------------------
Total 78 70.250000 3229.8000 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 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
94 142.250000 5593.6500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 94 142.250000 5593.6500 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 54 94.250000 3908.5500 0.0000
P 34 56.250000 2270.5500 2270.5500
D 1 1.000000 75.0000 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 42.500000 2471.8500 0.0000
Other 1 1.500000 55.8000 0.0000
---------------------------------------------------------
Total 118 195.500000 8781.7500 2270.5500
Center 05
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 219 203.750000 7579.5000 3645.6000
P 0 0.000000 0.0000 0.0000
D 1 1.000000 37.2000 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
0 0.000000 0.0000 0.0000
Other 2 1.250000 46.5000 0.0000
---------------------------------------------------------
Total 222 206.000000 7663.2000 3645.6000
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
223 274.750000 13280.5500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 223 274.750000 13280.5500 0.0000
Center 07
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 1 2.000000 111.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 40 45.000000 2161.8000 0.0000
P 109 146.000000 7063.2000 7063.2000
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 3 1.750000 65.1000 0.0000
---------------------------------------------------------
Total 153 194.750000 9401.1000 7063.2000
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 0 0.000000 0.0000 0.0000
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 117 185.750000 8823.4500 8823.4500
T 0 0.000000 0.0000 0.0000
41 71.500000 4969.3500 0.0000
Other 33 59.000000 4005.7500 0.0000
---------------------------------------------------------
Total 191 316.250000 17798.5500 8823.4500
Center 10
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 536 656.000000 31894.2000 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
4 12.750000 627.9000 0.0000
Other 4 1.500000 55.8000 0.0000
---------------------------------------------------------
Total 544 670.250000 32577.9000 0.0000
Center 51
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 1 1.000000 55.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 2 2.000000 138.7500 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
8 20.000000 1075.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 11 23.000000 1269.2500 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 32 44.000000 2199.6000 65.1000
P 73 108.250000 5515.2000 5515.2000
D 0 0.000000 0.0000 0.0000
S 28 26.750000 1146.3000 30.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
4 8.000000 600.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 137 187.000000 9461.1000 5610.3000
Center 53
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 33 36.000000 1890.5600 0.0000
P 207 236.000000 11149.3500 11149.3500
D 0 0.000000 0.0000 0.0000
S 23 31.750000 1237.8000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
25 30.000000 1677.6000 0.0000
Other 6 10.500000 691.8000 0.0000
---------------------------------------------------------
Total 294 344.250000 16647.1100 11149.3500
Center 54
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 6 5.750000 213.9000 0.0000
U 0 0.000000 0.0000 0.0000
B 62 81.500000 3595.8000 0.0000
P 430 553.750000 25327.2000 25327.2000
D 0 0.000000 0.0000 0.0000
S 1 1.500000 112.5000 0.0000
H 1 2.000000 111.0000 0.0000
T 0 0.000000 0.0000 0.0000
37 65.500000 4195.8000 0.0000
Other 2 4.000000 222.0000 0.0000
---------------------------------------------------------
Total 539 714.000000 33778.2000 25327.2000
Center 55
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 172 317.250000 16518.6000 0.0000
P 86 163.000000 7829.4000 6987.9000
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
39 78.000000 5187.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 297 558.250000 29535.0000 6987.9000
Center 57
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 205 374.000000 17862.3000 0.0000
P 5 6.000000 411.0000 411.0000
D 0 0.000000 0.0000 0.0000
S 2 3.500000 233.2500 0.0000
H 20 37.750000 1404.3000 1404.3000
T 0 0.000000 0.0000 0.0000
59 113.750000 4596.1500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 291 535.000000 24507.0000 1815.3000