CMS/EIP Fiscal Report Statewide
Services beginning 07/01/2022 ending 06/30/2023 Date of Report:07/25/2023 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
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 4 12.250000 455.7000 37.2000
Subtotal (Total Children Is Unduplicated) 4 12.250000 455.7000 37.2000
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Screening, Eval, and Assessment,Class #02
EVAL-96111-DEVELOPMENTAL EVALUATION 6 11.308600 565.4300 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 17 30.333333 2237.5000 73.7637
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 15 25.500000 1875.0000 73.5294
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 8 15.500000 1162.5000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 10 17.000000 1275.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 5 9.500000 712.5000 75.0000
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 8 15.000000 1125.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 8 17.000000 1275.0000 75.0000
IPDEF-T1024TLTSGT-F/U PHYC AND DEV EVAL BY EI PROF 7 11.000000 825.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 15 25.500000 1415.2500 55.5000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 18 34.500000 1914.7500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 330 605.759899 44206.2925 72.9766
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 403 701.833334 51976.2500 74.0578
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 123 227.905066 16727.4900 73.3967
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 216 359.000000 26783.8100 74.6067
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 115 211.758599 15450.1450 72.9611
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 179 293.000000 21742.7300 74.2073
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 237 419.000000 23004.7500 54.9039
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 562 952.500000 52472.5000 55.0892
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 135 228.565900 17046.2025 74.5789
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 176 298.000000 22099.8400 74.1605
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 20 20.000000 5624.3000 281.2150
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 1 1.000000 193.0000 193.0000
Subtotal (Total Children Is Unduplicated) 1507 4530.464731 311710.2400 68.8031
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 1 11.000000 550.0000 50.0000
Subtotal (Total Children Is Unduplicated) 1 11.000000 550.0000 50.0000
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Total 4553.714731 312715.9400 68.6727
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Number of Children (Unduplicated) With at Least One Service 1510
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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 92 135.000000 8347.5100 8347.5100
D 1 2.000000 150.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 152 215.000000 15042.7500 0.0000
T 18 27.500000 1875.7500 1875.7500
41 61.000000 4302.0000 0.0000
Other 10 15.000000 1056.7500 0.0000
---------------------------------------------------------
Total 314 455.500000 30774.7600 10223.2600
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 20 35.500000 2662.5000 2662.5000
1 2.000000 150.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 21 37.500000 2812.5000 2662.5000
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 66 120.000000 8193.8600 8193.8600
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 6 11.000000 727.5000 727.5000
T 0 0.000000 0.0000 0.0000
50 85.000000 5867.7500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 122 216.000000 14789.1100 8921.3600
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 30 32.000000 3316.0000 6351.7100
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
79 89.000000 9874.5500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 109 121.000000 13190.5500 6351.7100
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 3 4.500000 337.5000 337.5000
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 3 4.500000 337.5000 337.5000
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 12 18.000000 1084.5400 1084.5400
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
290 433.000000 29130.7500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 302 451.000000 30215.2900 1084.5400
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 66 128.066800 9605.0100 9605.0000
D 2 4.000000 300.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 17 34.000000 2550.0000 0.0000
T 0 0.000000 0.0000 0.0000
12 24.000000 1800.0000 0.0000
Other 1 2.000000 150.0000 0.0000
---------------------------------------------------------
Total 98 192.066800 14405.0100 9605.0000
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 98 185.000000 12783.7500 12785.1200
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 12.000000 783.0000 783.0000
64 108.000000 6881.2500 0.0000
Other 21 41.500000 2995.5000 0.0000
---------------------------------------------------------
Total 189 346.500000 23443.5000 13568.1200
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
421 760.500000 51039.7500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 421 760.500000 51039.7500 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 37 73.500000 4567.2500 3331.8400
D 48 96.000000 5757.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 41 81.500000 5888.2500 0.0000
T 96 190.500000 12073.6000 11192.8000
30 60.000000 4010.4500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 252 501.500000 32296.5500 14524.6400
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 35 50.000000 3058.9500 0.0000
S 0 0.000000 0.0000 0.0000
H 9 14.000000 1050.0000 0.0000
T 10 18.500000 1085.2500 1085.2500
52 81.250000 5657.7000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 106 163.750000 10851.9000 1085.2500
Center 54
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 0 0.000000 0.0000 0.0000
P 0 0.000000 0.0000 0.0000
D 16 23.000000 1306.8000 0.0000
S 0 0.000000 0.0000 0.0000
H 18 32.000000 2400.0000 0.0000
T 47 85.000000 5127.0000 5127.0000
102 186.000000 13131.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 183 326.000000 21964.8000 5127.0000
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 50 100.000000 7500.0000 7500.0000
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 42 84.000000 6250.0000 0.0000
T 0 0.000000 0.0000 0.0000
95 149.897931 11009.6300 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 187 333.897931 24759.6300 7500.0000
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 14 25.000000 1650.7500 2883.7600
D 57 95.500000 6265.5000 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 7 13.500000 1012.5000 1012.5000
304 510.000000 32906.3400 150.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 382 644.000000 41835.0900 4046.2600