CMS/EIP Fiscal Report Statewide
Services beginning 04/01/2020 ending 06/30/2020 Date of Report:07/21/2020 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 14993 50404.00000 1864445.7500 36.9900
Subtotal (Total Children Is Unduplicated) 14993 50404.00000 1864445.7500 36.9900
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 10 17.500000 1312.5000 75.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 60 95.500000 7162.5000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 2.000000 150.0000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 30 41.000000 3075.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 3 4.500000 337.5000 75.0000
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 22 37.000000 2775.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 6 6.000000 450.0000 75.0000
IPDEF-T1024TLTSGT-F/U PHYC AND DEV EVAL BY EI PROF 35 58.000000 4325.0000 74.5690
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 9 15.500000 860.2500 55.5000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 82 129.000000 7159.5000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 51 100.000000 7500.0000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 946 1630.670133 122116.5100 74.8873
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 24 46.000000 3450.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 397 663.500000 49762.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 17 27.000000 2025.0000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 439 765.500000 57373.5000 74.9491
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 55 104.000000 5772.0000 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 1231 2062.500000 114408.9000 55.4710
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 40 69.000000 5175.0000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 470 879.500000 65962.5000 75.0000
OCTF-97168-OT RE-EVAL EST PLAN CARE 1 1.000000 51.0500 51.0500
OCTF-97168GT-OT RE-EVAL EST PLAN CARE 2 2.000000 102.1000 51.0500
OCTH-97165TLGT-OT EVAL LOW COMPLEXITY 1 3.000000 153.1500 51.0500
OCTH-97166-OT EVAL MODERATE COMPLEXITY 2 2.000000 102.1000 51.0500
OCTH-97166GT-OT EVAL MODERATE COMPLEXITY 2 2.000000 102.1000 51.0500
OCTH-97166TL-OT EVAL MODERATE COMPLEXITY 1 1.000000 51.0500 51.0500
OCTH-97166TLGT-OT EVAL MODERATE COMPLEXITY 1 1.000000 51.0500 51.0500
OCTH-97167-OT EVAL HIGH COMPLEXITY 14 14.000000 714.7000 51.0500
OCTH-97167GT-OT EVAL HIGH COMPLEXITY 10 10.000000 510.5000 51.0500
OCTH-97167TLGT-OT EVAL HIGH COMPLEXITY 2 2.000000 102.1000 51.0500
PSTF-97164-PT RE-EVAL EST PLAN CARE 1 1.000000 51.0500 51.0500
PSTH-97162-PT EVAL MODERATE COMPLEXITY 1 1.000000 51.0500 51.0500
PSTH-97162GT-PT EVAL MODERATE COMPLEXITY 5 5.000000 255.2500 51.0500
PSTH-97163-PT EVAL HIGH COMPLEXITY 8 9.000000 459.4500 51.0500
PSTH-97163GT-PT EVAL HIGH COMPLEXITY 13 13.000000 663.6500 51.0500
SCREEN-T1023-SCREENING 47 49.000000 2450.0000 50.0000
SPCH-92521GT-EVAL OF SPEECH FLUENCY 1 1.000000 51.0500 51.0500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 10 10.000000 510.5000 51.0500
SPCH-92523GT-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 3 3.000000 153.1500 51.0500
SPCH-92523TL-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 9 9.000000 459.4500 51.0500
SPCH-92523TLGT-EVAL OF SPCH SOUND PROD; EVAL LANG COM 7 7.000000 357.3500 51.0500
SPCH-92524GT-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
SPCH-92610TLGT-EVAL OF ORAL,PHARYNGEAL SWALLOWING FUN 1 1.000000 44.5500 44.5500
Subtotal (Total Children Is Unduplicated) 2140 6906.670133 468903.7500 67.8914
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 1 3.000000 639.5400 213.1800
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 1776 9286.500000 464265.0000 49.9935
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 3353 20490.75000 1024497.5000 49.9980
OCCT-97530-OT SESSION BY LICENSED OT 155 655.250000 46811.0600 71.4400
OCCT-97530GT-OT SESSION BY LICENSED OT 204 885.500000 63260.1200 71.4400
OCCT-97530HM-OT SESSION BY OT ASST 64 202.750000 11597.3000 57.2000
OCCT-97530HMGT-OT SESSION BY OT ASST 45 224.000000 12812.8000 57.2000
OCCT-97530TL-OT SESSION BY LICENSED OT 24 53.750000 3768.4600 70.1109
OCCT-97530TLGT-OT SESSION BY LICENSED OT 124 470.750000 33630.3800 71.4400
OCCT-97530TLGTHM-OT SESSION BY OT ASST 8 28.000000 1601.6000 57.2000
OCCT-97530TLHM-OT SESSION BY OT ASST 3 4.000000 228.8000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 218 812.250000 58027.1400 71.4400
PHY-97110GT-PT SESSION BY LICENSED PT 217 782.000000 55495.2600 70.9658
PHY-97110HM-PT SESSION BY PT ASST 42 255.500000 14604.3800 57.1600
PHY-97110HMGT-PT SESSION BY LICENSED PT ASST 11 29.250000 1671.9300 57.1600
PHY-97110TL-PT SESSION BY LICENSED PT 36 79.750000 5697.3400 71.4400
PHY-97110TLGT-PT SESSION BY LICENSED PT 96 396.000000 28229.4000 71.2864
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 283 1313.000000 93800.7200 71.4400
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 337 1398.000000 99873.1200 71.4400
SPL-92507TL-SPL THERAPY SESSION BY LICENSED SLP 71 211.500000 15109.5600 71.4400
SPL-92507TLGT-SPL THERAPY SESSION BY LICENSED SLP 154 556.750000 39774.2200 71.4400
SPL-92508TLGT-SPL THERAPY SESSION BY LICENSED SLP 9 10.500000 145.7400 13.8800
Subtotal (Total Children Is Unduplicated) 5573 38148.75000 2075541.3700 54.4065
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Total 95459.420133 4408890.8700 46.1860
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Number of Children (Unduplicated) With at Least One Service 15612
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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 1 0.750000 27.7500 0.0000
P 0 0.000000 0.0000 0.0000
D 100 99.000000 5116.7800 0.0000
S 4381 2918.000000 119552.9100 0.0000
H 7023 4790.500000 200601.3100 200601.3100
T 0 0.000000 0.0000 0.0000
22 18.000000 701.7500 0.0000
Other 77 127.000000 8999.5000 0.0000
---------------------------------------------------------
Total 11604 7953.250000 335000.0000 200601.3100
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 1613 1012.250000 45023.5000 0.0000
---------------------------------------------------------
Total 1613 1012.250000 45023.5000 0.0000
Center 03
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 179 147.500000 5954.9600 0.0000
U 0 0.000000 0.0000 0.0000
B 3213 2142.250000 83145.2500 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
67 69.250000 4498.7800 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 3459 2359.000000 93598.9900 0.0000
Center 04
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 450 592.500000 21922.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 3026 4382.250000 162128.2500 0.0000
P 552 745.500000 29138.2000 25866.4200
D 0 0.000000 0.0000 0.0000
S 1 2.000000 74.0000 0.0000
H 1701 5874.250000 299584.7000 0.0000
T 0 0.000000 0.0000 0.0000
284 323.000000 21136.7500 0.0000
Other 3 8.000000 434.1000 200.0000
---------------------------------------------------------
Total 6017 11927.500000 534418.5000 26066.4200
Center 05
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 28 33.500000 2121.8200 0.0000
U 0 0.000000 0.0000 0.0000
B 3137 2012.250000 75627.4000 44146.0000
P 0 0.000000 0.0000 0.0000
D 2 2.000000 131.0000 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
5 3.250000 120.2500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 3172 2051.000000 78000.4700 44146.0000
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
11148 8868.750000 408326.3200 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 11148 8868.750000 408326.3200 0.0000
Center 07
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 18 17.500000 647.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 1116 807.000000 32059.2500 0.0000
P 2681 2003.750000 81831.5000 81790.8000
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
17 16.000000 592.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 3832 2844.250000 115130.2500 81790.8000
Center 09
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 40 51.500000 2183.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 626 701.250000 27478.0000 0.0000
P 3914 4082.750000 162166.2500 162166.2500
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 3 13.000000 481.0000 425.5000
1586 5198.250000 287939.9400 0.0000
Other 163 318.000000 23206.5000 0.0000
---------------------------------------------------------
Total 6332 10364.750000 503455.1900 162591.7500
Center 10
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 491 376.000000 14234.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 2750 2030.750000 82615.5000 0.0000
P 7231 5171.500000 212538.8900 211526.4250
D 85 54.250000 2157.2500 0.0000
S 138 259.000000 17374.7500 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
2856 9196.250000 506953.8600 0.0000
Other 2 1.750000 64.7500 0.0000
---------------------------------------------------------
Total 13553 17089.500000 835939.0000 211526.4250
Center 51
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 15 8.000000 296.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 932 719.250000 28839.1700 0.0000
P 3 2.500000 99.0000 74.0000
D 15 13.000000 481.0000 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
165 388.750000 24829.5200 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 1130 1131.500000 54544.6900 74.0000
Center 52
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 3 6.000000 450.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 1373 1417.500000 63314.7000 0.0000
P 277 250.250000 9505.4400 9560.9400
D 0 0.000000 0.0000 0.0000
S 324 355.500000 13832.2400 46.7500
H 0 0.000000 0.0000 0.0000
T 1 1.000000 37.0000 0.0000
657 1210.000000 73627.3200 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 2635 3240.250000 160766.7000 9607.6900
Center 53
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 27 17.000000 760.0700 0.0000
U 0 0.000000 0.0000 0.0000
B 2546 2177.500000 103948.4600 0.0000
P 963 853.000000 41094.6700 40907.8800
D 144 118.250000 5359.4300 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
1684 1617.500000 81445.0400 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 5364 4783.250000 232607.6700 40907.8800
Center 54
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 7 4.500000 261.2100 0.0000
U 0 0.000000 0.0000 0.0000
B 2461 2054.750000 92940.9600 9.2500
P 1608 1322.750000 57413.1600 57276.0900
D 60 38.500000 1450.3300 9.2500
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
4585 4426.000000 216496.4600 0.0000
Other 1 1.000000 37.0000 0.0000
---------------------------------------------------------
Total 8722 7847.500000 368599.1200 57294.5900
Center 55
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 2631 2254.583333 99733.0900 92.5000
P 2211 1388.250000 54906.3100 55758.4100
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
2530 2551.000000 154464.1100 0.0000
Other 1 0.836800 62.7600 0.0000
---------------------------------------------------------
Total 7373 6194.670133 309166.2700 55850.9100
Center 57
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 1 0.250000 9.2500 0.0000
U 0 0.000000 0.0000 0.0000
B 687 798.250000 31330.7500 157.2500
P 4331 4370.250000 171013.5000 168361.8000
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 2 2.000000 150.0000 0.0000
T 0 0.000000 0.0000 0.0000
863 2621.250000 131810.7000 131810.7000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 5884 7792.000000 334314.2000 300329.7500