CMS/EIP Fiscal Report Statewide
Services beginning 10/01/2019 ending 12/31/2019 Date of Report:02/01/2020 Page: 1
List order: No List
Payclass Filters:MED
Eligibility Filter:Program Patients
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 15877 48194.00000 1782096.7500 36.9776
Subtotal (Total Children Is Unduplicated) 15877 48194.00000 1782096.7500 36.9776
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 104 158.000000 11850.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 68 100.500000 7500.0000 74.6269
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 45 64.000000 4800.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 93 155.500000 11662.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 164 249.500000 13847.2500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 1521 2446.500000 183468.0000 74.9920
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 825 1282.871733 96186.1300 74.9772
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 546 864.000000 64722.0000 74.9097
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 2323 3566.000000 197829.7500 55.4767
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 920 1491.803467 111810.2600 74.9497
OCTF-97168-OT RE-EVAL EST PLAN CARE 5 5.000000 255.2500 51.0500
OCTH-97165-OT EVAL LOW COMPLEXITY 4 4.000000 204.2000 51.0500
OCTH-97166-OT EVAL MODERATE COMPLEXITY 11 11.000000 561.5500 51.0500
OCTH-97167-OT EVAL HIGH COMPLEXITY 69 69.000000 3522.4500 51.0500
PSTF-97164-PT RE-EVAL EST PLAN CARE 3 3.000000 153.1500 51.0500
PSTH-97161-PT EVAL LOW COMPLEXITY 2 2.000000 102.1000 51.0500
PSTH-97162-PT EVAL MODERATE COMPLEXITY 12 12.000000 612.6000 51.0500
PSTH-97163-PT EVAL HIGH COMPLEXITY 32 33.000000 1684.6500 51.0500
SCREEN-T1023-SCREENING 73 81.000000 4050.0000 50.0000
SPCH-92521-EVAL OF SPEECH FLUENCY 1 1.000000 51.0500 51.0500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 36 38.000000 1939.9000 51.0500
SPCH-92524-BEHAV & QUAL ANALYSIS OF VOICE AND RES 5 5.000000 255.2500 51.0500
SPCH-92610-EVAL OF ORAL,PHARYNGEAL SWALLOWING FUNC 1 1.000000 48.9400 48.9400
Subtotal (Total Children Is Unduplicated) 3645 10643.67520 717116.9800 67.3749
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 3 31.000000 3014.4600 97.2406
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 27 67.750000 1693.7500 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 6484 49167.75000 2458204.0000 49.9963
OCCT-97530-OT SESSION BY LICENSED OT 610 2801.927212 199981.9400 71.3730
OCCT-97530HM-OT SESSION BY OT ASST 248 1233.250000 70541.8600 57.2000
PHY-97110-PT SESSION BY LICENSED PT 624 3094.750000 220828.1600 71.3557
PHY-97110HM-PT SESSION BY PT ASST 95 493.125262 28187.0400 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 872 5228.000000 372445.5900 71.2405
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 1 2.000000 114.4000 57.2000
SPL-92508-GROUP SPL SESSION PER CHILD 16 39.750000 551.7300 13.8800
Subtotal (Total Children Is Unduplicated) 7887 62159.30247 3355562.9300 53.9833
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Total 120996.977674 5854776.6600 48.3878
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Number of Children (Unduplicated) With at Least One Service 17292
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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 202 201.250000 14319.3000 0.0000
P 2 2.000000 100.0000 100.0000
D 93 94.500000 4788.1000 0.0000
S 2531 1929.000000 84774.8700 0.0000
H 6798 4966.750000 208517.6200 208392.6000
T 0 0.000000 0.0000 0.0000
13 6.750000 284.1900 0.0000
Other 339 544.000000 34706.2500 0.0000
---------------------------------------------------------
Total 9978 7744.250000 347490.3300 208492.6000
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 1774 1223.750000 54974.7500 0.0000
---------------------------------------------------------
Total 1774 1223.750000 54974.7500 0.0000
Center 03
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 43 32.000000 1221.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 3212 2452.750000 104620.8400 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
46 59.500000 3847.7300 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 3301 2544.250000 109689.5700 0.0000
Center 04
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 516 792.250000 29313.2500 0.0000
U 0 0.000000 0.0000 0.0000
B 1109 1654.250000 65618.0000 46.2500
P 3045 4646.250000 184091.4000 179553.9400
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 2720 10354.500000 527702.1600 0.0000
T 0 0.000000 0.0000 0.0000
202 168.500000 11148.7500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 7592 17615.750000 817873.5600 179600.1900
Center 05
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 2610 1773.500000 69898.1700 42287.0000
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
2 0.500000 18.5000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 2612 1774.000000 69916.6700 42287.0000
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 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
11139 9686.250000 473032.9500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 11139 9686.250000 473032.9500 0.0000
Center 07
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 120 133.500000 4952.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 620 536.250000 21968.5000 0.0000
P 3011 2749.000000 119809.0000 119836.4500
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
114 85.500000 3276.5000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 3865 3504.250000 150006.5000 119836.4500
Center 09
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 2 0.500000 18.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 178 187.250000 7501.0000 120.2500
P 4251 4763.000000 193056.5000 193056.5000
D 6 5.500000 279.5000 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 3 4.500000 240.5000 425.5000
2424 7585.500000 427351.0800 0.0000
Other 197 338.000000 24501.7500 0.0000
---------------------------------------------------------
Total 7061 12884.250000 652948.8300 193602.2500
Center 10
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 189 163.750000 6058.7500 0.0000
U 0 0.000000 0.0000 0.0000
B 3617 2974.500000 122701.0000 18.5000
P 6180 5104.000000 218829.3000 217635.9580
D 8 9.750000 360.7500 0.0000
S 34 86.000000 4300.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
4575 14240.500000 768663.0300 0.0000
Other 1 0.500000 18.5000 0.0000
---------------------------------------------------------
Total 14604 22579.000000 1120931.3300 217654.4580
Center 51
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 5 5.000000 277.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 636 422.000000 16791.2500 0.0000
P 42 43.000000 2249.0000 2379.5000
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
1720 2648.500000 145131.4900 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 2403 3118.500000 164449.2400 2379.5000
Center 52
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 13 12.500000 547.0000 18.5000
U 0 0.000000 0.0000 0.0000
B 312 303.500000 14945.7300 0.0000
P 1807 1789.500000 81799.9500 81591.3500
D 0 0.000000 0.0000 0.0000
S 241 209.250000 7840.7500 0.0000
H 39 37.750000 2523.5800 74.9000
T 1 0.250000 9.2500 0.0000
1146 2284.500000 137671.9500 0.0000
Other 1 0.250000 9.2500 9.2500
---------------------------------------------------------
Total 3560 4637.500000 245347.4600 81694.0000
Center 53
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 37 30.500000 1294.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 1789 1688.500000 79867.0000 50.0000
P 1702 1651.250000 78498.1000 78357.6800
D 88 80.750000 5579.6200 0.0000
S 0 0.000000 0.0000 0.0000
H 28 29.250000 2030.9300 0.0000
T 0 0.000000 0.0000 0.0000
1432 1485.750000 76863.0800 0.0000
Other 29 27.000000 1793.8300 0.0000
---------------------------------------------------------
Total 5105 4993.000000 245927.0600 78407.6800
Center 54
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 136 144.750000 5649.6400 0.0000
U 0 0.000000 0.0000 0.0000
B 2692 2148.000000 98999.6900 55.5000
P 3326 2674.000000 118386.4300 5048115.1700
D 87 85.750000 5419.5100 0.0000
S 0 0.000000 0.0000 0.0000
H 23 23.750000 1700.5500 0.0000
T 0 0.000000 0.0000 0.0000
2972 3080.250000 160561.7200 0.0000
Other 50 52.250000 3706.2900 64.7500
---------------------------------------------------------
Total 9286 8208.750000 394423.8300 5048235.4200
Center 55
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 1025 863.250000 36804.5000 0.0000
P 3084 2715.750000 112422.5000 112153.0000
D 0 0.000000 0.0000 0.0000
S 1 1.303467 97.7600 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
5088 5346.174207 323294.6000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 9198 8926.477674 472619.3600 112153.0000
Center 57
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 1 1.000000 37.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 379 458.250000 17763.7500 55.0000
P 3571 4200.750000 169972.2500 166599.0200
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 12 14.500000 1087.5000 0.0000
T 1 1.000000 50.0000 50.0000
1935 6881.000000 346216.2200 346200.8900
Other 1 0.500000 18.5000 18.5000
---------------------------------------------------------
Total 5900 11557.000000 535145.2200 512923.4100