CMS/EIP Fiscal Report Statewide
Services beginning 10/01/2020 ending 12/31/2020 Date of Report:01/23/2021 Page: 1
List order: No List
Payclass Filters:MED
Bill Flag Filter:RBPU
Eligibility Filter:All
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 10694 37320.75000 1380024.3000 36.9774
Subtotal (Total Children Is Unduplicated) 10694 37320.75000 1380024.3000 36.9774
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 2 4.000000 300.0000 75.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 47 75.000000 5625.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 2 3.000000 225.0000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 32 48.500000 3637.5000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 2 3.500000 262.5000 75.0000
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 10 15.000000 1125.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 1 1.000000 75.0000 75.0000
IPDEF-T1024TLTSGT-F/U PHYC AND DEV EVAL BY EI PROF 26 46.000000 3450.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 8 15.000000 832.5000 55.5000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 51 75.500000 4134.7500 54.7649
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 72 141.000000 10575.0000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 858 1516.000000 113550.7500 74.9016
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 20 36.000000 2700.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 371 580.500000 43537.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 27 53.000000 3975.0000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 254 411.500000 30787.5000 74.8177
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 155 305.500000 16955.2500 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 853 1376.000100 76368.0055 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 91 177.000000 13236.0000 74.7797
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 322 566.000000 42450.0000 75.0000
OCTH-97166TLGT-OT EVAL MODERATE COMPLEXITY 1 1.000000 51.0500 51.0500
PSTH-97161-PT EVAL LOW COMPLEXITY 1 1.000000 51.0500 51.0500
SCREEN-T1023-SCREENING 7 7.000000 350.0000 50.0000
SPCH-92522-EVAL OF SPCH SOUND PROD 1 1.000000 51.0500 51.0500
SPCH-92523-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 7 7.000000 357.3500 51.0500
SPCH-92523TLGT-EVAL OF SPCH SOUND PROD; EVAL LANG COM 2 2.000000 102.1000 51.0500
Subtotal (Total Children Is Unduplicated) 1946 5471.000100 374918.0055 68.5282
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EI Services,Class #03
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 3 1.500000 37.5000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 103 481.500000 24075.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 344 1252.250000 62612.5000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 1 5.500000 392.9200 71.4400
OCCT-97530GT-OT SESSION BY LICENSED OT 9 14.000000 1000.1600 71.4400
OCCT-97530HM-OT SESSION BY OT ASST 1 4.000000 228.8000 57.2000
OCCT-97530TL-OT SESSION BY LICENSED OT 3 5.000000 357.2000 71.4400
OCCT-97530TLGT-OT SESSION BY LICENSED OT 92 368.250000 26307.7800 71.4400
PHY-97110-PT SESSION BY LICENSED PT 10 20.750000 1482.3800 71.4400
PHY-97110GT-PT SESSION BY LICENSED PT 9 36.750000 2625.4200 71.4400
PHY-97110TL-PT SESSION BY LICENSED PT 10 15.000000 1071.6000 71.4400
PHY-97110TLGT-PT SESSION BY LICENSED PT 60 251.500000 17967.1600 71.4400
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 8 16.000000 1143.0400 71.4400
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 5 10.250000 732.2600 71.4400
SPL-92507TL-SPL THERAPY SESSION BY LICENSED SLP 42 238.250000 17020.5800 71.4400
SPL-92507TLGT-SPL THERAPY SESSION BY LICENSED SLP 106 460.000000 32862.4000 71.4400
SPL-92508TLGT-SPL THERAPY SESSION BY LICENSED SLP 1 1.000000 13.8800 13.8800
Subtotal (Total Children Is Unduplicated) 751 3181.500000 189930.5800 59.6984
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Total 45973.250100 1944872.8855 42.3044
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Number of Children (Unduplicated) With at Least One Service 10829
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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 8 2.000000 74.0000 0.0000
P 1 1.000000 50.0000 50.0000
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 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 9 3.000000 124.0000 50.0000
Center 03
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 3665 2743.500000 117001.9200 0.0000
P 47 46.750000 2404.4400 2357.4400
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 3712 2790.250000 119406.3600 2357.4400
Center 04
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 87 135.250000 5061.2500 0.0000
U 0 0.000000 0.0000 0.0000
B 2518 4067.250000 159728.7500 0.0000
P 1044 1727.250000 67463.2500 66848.5000
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 3649 5929.750000 232253.2500 66848.5000
Center 05
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 5 3.750000 233.7500 0.0000
U 0 0.000000 0.0000 0.0000
B 2823 2049.500000 78461.4100 13449.5050
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 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 2828 2053.250000 78695.1600 13449.5050
Center 07
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 14 20.500000 1366.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 733 599.500000 23677.0000 0.0000
P 3005 2533.250000 109216.0000 108942.2000
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 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 3752 3153.250000 134259.5000 108942.2000
Center 09
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 12 10.500000 370.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 800 878.250000 33354.5000 0.0000
P 2799 3096.000000 125437.7500 125437.7500
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 3611 3984.750000 159162.2500 125437.7500
Center 10
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 305 227.750000 8898.7500 0.0000
U 0 0.000000 0.0000 0.0000
B 1525 1207.750000 47606.5000 0.0000
P 7234 5978.250000 251119.5100 252866.1000
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 9064 7413.750000 307624.7600 252866.1000
Center 51
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 1 2.000000 0.7500 0.0000
U 0 0.000000 0.0000 0.0000
B 20 16.250000 1102.0000 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 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 21 18.250000 1102.7500 0.0000
Center 52
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 6 6.250000 307.2500 0.0000
U 0 0.000000 0.0000 0.0000
B 449 478.250000 24824.6200 0.0000
P 1567 1665.500000 73974.3500 73855.6800
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 2022 2150.000000 99106.2200 73855.6800
Center 53
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 11 11.750000 469.1900 0.0000
U 0 0.000000 0.0000 0.0000
B 3414 3075.750000 145865.0400 0.0000
P 1376 1337.250100 62490.3955 62180.6400
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 4801 4424.750100 208824.6255 62180.6400
Center 54
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 35 44.750000 1655.7500 0.0000
U 0 0.000000 0.0000 0.0000
B 4011 3693.500000 167466.4900 105.0500
P 1914 1683.250000 75557.6500 75354.1500
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 5960 5421.500000 244679.8900 75459.2000
Center 55
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 3404 2934.500000 127662.3200 0.0000
P 484 400.750000 16514.5500 37928.8500
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 3888 3335.250000 144176.8700 37928.8500
Center 57
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 8 8.750000 323.7500 0.0000
U 0 0.000000 0.0000 0.0000
B 740 903.000000 34858.5600 148.0000
P 3728 4383.750000 180274.9400 179122.1900
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 4476 5295.500000 215457.2500 179270.1900