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
Eligibility Filter:Part C (excluding not eligible)
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 13454 44468.75000 1644235.0500 36.9751
Subtotal (Total Children Is Unduplicated) 13454 44468.75000 1644235.0500 36.9751
-----------------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 8 13.500000 1012.5000 75.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 54 85.500000 6412.5000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 3 5.000000 375.0000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 43 66.500000 4958.2500 74.5602
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 16 28.000000 2061.0000 73.6071
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 16 37.000000 2775.0000 75.0000
IPDEF-T1024TLTSGT-F/U PHYC AND DEV EVAL BY EI PROF 35 67.500000 5062.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 17 32.000000 1776.0000 55.5000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 86 138.500000 7631.2500 55.0993
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 111 211.000000 15825.0000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 1015 1776.333333 133075.7500 74.9160
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 53 91.500000 6862.5000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 553 910.500000 68287.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 33 63.000000 4725.0000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 353 616.000000 46125.0000 74.8782
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 206 394.000000 21867.0000 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 1310 2188.000000 121434.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 98 189.000000 14136.0000 74.7937
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 449 796.000000 59700.0000 75.0000
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 14 14.000000 824.7400 58.9100
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 3 3.000000 70.2600 23.4200
OCTF-97168-OT RE-EVAL EST PLAN CARE 5 5.000000 255.2500 51.0500
OCTF-97168GT-OT RE-EVAL EST PLAN CARE 4 4.000000 204.2000 51.0500
OCTH-97166-OT EVAL MODERATE COMPLEXITY 6 6.000000 306.3000 51.0500
OCTH-97166GT-OT EVAL MODERATE COMPLEXITY 1 1.000000 51.0500 51.0500
OCTH-97166TL-OT EVAL MODERATE COMPLEXITY 7 7.000000 357.3500 51.0500
OCTH-97166TLGT-OT EVAL MODERATE COMPLEXITY 2 2.000000 102.1000 51.0500
OCTH-97167-OT EVAL HIGH COMPLEXITY 34 34.000000 1735.7000 51.0500
OCTH-97167GT-OT EVAL HIGH COMPLEXITY 6 6.000000 306.3000 51.0500
OCTH-97167TL-OT EVAL HIGH COMPLEXITY 1 1.000000 51.0500 51.0500
PSTF-97164GT-PT RE-EVAL EST PLAN CARE 2 2.000000 102.1000 51.0500
PSTH-97161-PT EVAL LOW COMPLEXITY 2 2.000000 102.1000 51.0500
PSTH-97162GT-PT EVAL MODERATE COMPLEXITY 5 5.000000 255.2500 51.0500
PSTH-97162TL-PT EVAL MODERATE COMPLEXITY 1 1.000000 51.0500 51.0500
PSTH-97163-PT EVAL HIGH COMPLEXITY 18 18.000000 918.9000 51.0500
PSTH-97163GT-PT EVAL HIGH COMPLEXITY 3 3.000000 153.1500 51.0500
PSTH-97163TL-PT EVAL HIGH COMPLEXITY 2 2.000000 102.1000 51.0500
SCREEN-T1023-SCREENING 25 25.000000 1250.0000 50.0000
SPCH-92522-EVAL OF SPCH SOUND PROD 2 2.000000 102.1000 51.0500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 21 21.000000 1072.0500 51.0500
SPCH-92523GT-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 6 6.000000 306.3000 51.0500
SPCH-92523TL-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 15 15.000000 765.7500 51.0500
SPCH-92523TLGT-EVAL OF SPCH SOUND PROD; EVAL LANG COM 3 3.000000 153.1500 51.0500
SPCH-92524-BEHAV & QUAL ANALYSIS OF VOICE AND RES 12 12.000000 612.6000 51.0500
SPCH-92524GT-BEHAV & QUAL ANALYSIS OF VOICE AND RES 3 3.000000 153.1500 51.0500
Subtotal (Total Children Is Unduplicated) 2438 7915.333333 534728.3000 67.5560
-----------------------------------------------------------------------------------------------------------------------
EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 5 9.000000 4477.7800 497.5311
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 4 6.500000 162.5000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 3128 21915.75000 1095698.5000 49.9959
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 2008 10077.25000 503787.5000 49.9926
OCCT-97530-OT SESSION BY LICENSED OT 376 1510.750000 107927.9800 71.4400
OCCT-97530GT-OT SESSION BY LICENSED OT 96 343.250000 24343.1800 70.9197
OCCT-97530HM-OT SESSION BY OT ASST 138 840.500000 48076.6000 57.2000
OCCT-97530HMGT-OT SESSION BY OT ASST 17 75.000000 4290.0000 57.2000
OCCT-97530TL-OT SESSION BY LICENSED OT 53 251.500000 17967.1600 71.4400
OCCT-97530TLGT-OT SESSION BY LICENSED OT 110 420.000000 30004.8000 71.4400
OCCT-97530TLGTHM-OT SESSION BY OT ASST 5 15.500000 886.6000 57.2000
OCCT-97530TLHM-OT SESSION BY OT ASST 8 16.500000 943.8000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 390 1704.500000 121769.4800 71.4400
PHY-97110GT-PT SESSION BY LICENSED PT 137 433.250000 30908.5000 71.3410
PHY-97110HM-PT SESSION BY PT ASST 63 313.500000 17919.6600 57.1600
PHY-97110HMGT-PT SESSION BY LICENSED PT ASST 8 17.000000 971.7200 57.1600
PHY-97110TL-PT SESSION BY LICENSED PT 44 193.500000 13823.6400 71.4400
PHY-97110TLGT-PT SESSION BY LICENSED PT 66 274.500000 19610.2800 71.4400
PHY-97110TLGTHM-PT SESSION BY PT ASST 3 14.000000 800.2400 57.1600
PHY-97110TLHM-PT SESSION BY PT ASST 7 33.000000 1886.2800 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 549 2874.500000 204437.2000 71.1210
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 175 791.000000 56509.0400 71.4400
SPL-92507TL-SPL THERAPY SESSION BY LICENSED SLP 143 677.000000 48364.8800 71.4400
SPL-92507TLGT-SPL THERAPY SESSION BY LICENSED SLP 119 568.250000 40595.7800 71.4400
SPL-92508-GROUP SPL SESSION PER CHILD 7 17.750000 246.3700 13.8800
SPL-92508TLGT-SPL THERAPY SESSION BY LICENSED SLP 1 1.000000 13.8800 13.8800
CMS/EIP Fiscal Report Statewide
Services beginning 10/01/2020 ending 12/31/2020 Date of Report:01/23/2021 Page: 2
List order: No List
Payclass Filters:MED
Eligibility Filter:Part C (excluding not eligible)
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Subtotal (Total Children Is Unduplicated) 6087 43394.25000 2396423.3500 55.2244
-----------------------------------------------------------------------------------------------------------------------
Total 95778.333333 4575386.7000 47.7706
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 14568
-----------------------------------------------------------------------------------------------------------------------
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 80 80.250000 4141.6900 0.0000
S 3503 2248.750000 100991.4200 0.0000
H 5444 3189.500000 131324.2500 117907.7500
T 1 0.250000 9.2500 0.0000
20 7.250000 268.2500 0.0000
Other 234 265.250000 16799.7500 0.0000
---------------------------------------------------------
Total 9291 5794.250000 253658.6100 117957.7500
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 1123 828.000000 37445.0000 0.0000
---------------------------------------------------------
Total 1123 828.000000 37445.0000 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 3529 2563.250000 108901.4200 0.0000
P 47 46.750000 2404.4400 2357.4400
D 53 33.750000 1248.7500 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
19 17.500000 1220.1500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 3648 2661.250000 113774.7600 2357.4400
Center 04
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 83 128.250000 4802.2500 0.0000
U 0 0.000000 0.0000 0.0000
B 2397 3867.750000 151319.0000 0.0000
P 1016 1676.750000 65481.7500 64867.0000
D 91 149.750000 5925.5000 0.0000
S 0 0.000000 0.0000 0.0000
H 1595 5817.000000 295393.1900 0.0000
T 0 0.000000 0.0000 0.0000
419 568.750000 27654.2500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 5601 12208.250000 550575.9400 64867.0000
Center 05
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 4 2.750000 158.7500 0.0000
U 0 0.000000 0.0000 0.0000
B 2685 1914.750000 73247.6600 12339.5050
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
3 1.750000 64.7500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 2692 1919.250000 73471.1600 12339.5050
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
10989 8741.250000 406367.8600 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 10989 8741.250000 406367.8600 0.0000
Center 07
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 14 20.500000 1366.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 696 558.750000 22017.2500 0.0000
P 2899 2395.250000 102606.0000 102332.2000
D 0 0.000000 0.0000 0.0000
S 1 1.000000 50.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
56 33.000000 1221.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 3666 3008.500000 127260.7500 102332.2000
Center 09
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 12 10.500000 370.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 769 824.000000 31310.2500 0.0000
P 2716 2951.500000 118463.7500 118463.7500
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 6 18.500000 758.5000 536.5000
1779 5931.000000 331839.0500 0.0000
Other 140 276.000000 19003.5000 0.0000
---------------------------------------------------------
Total 5422 10011.500000 501745.0500 119000.2500
Center 10
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 285 206.000000 7980.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 1475 1144.500000 44993.5000 0.0000
P 6923 5622.750000 233830.2600 235842.1500
D 75 92.500000 5618.5000 0.0000
S 96 177.000000 12134.2500 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
3368 10204.750000 580993.2500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 12222 17447.500000 885549.7600 235842.1500
Center 51
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 1 2.000000 0.7500 0.0000
U 0 0.000000 0.0000 0.0000
B 10 7.750000 532.7500 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
812 1840.750000 108476.2200 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 823 1850.500000 109009.7200 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 429 449.750000 23363.8700 0.0000
P 1486 1532.000000 67422.1000 67303.4000
D 2 2.000000 70.0000 0.0000
S 271 281.000000 12103.7100 155.0500
H 9 9.000000 581.5200 0.0000
T 0 0.000000 0.0000 0.0000
728 1570.500000 97155.9100 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 2931 3850.500000 201004.3600 67458.4500
Center 53
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 11 11.750000 469.1900 0.0000
U 0 0.000000 0.0000 0.0000
B 3197 2848.250000 135143.0400 0.0000
P 1255 1208.000000 56348.6400 56038.8900
D 57 56.000000 3152.1000 0.0000
S 7 7.000000 350.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 2 4.000000 222.0000 0.0000
990 1022.000000 52754.8600 0.0000
Other 19 15.000000 1037.1600 37.0000
---------------------------------------------------------
Total 5538 5172.000000 249476.9900 56075.8900
Center 54
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 35 44.750000 1655.7500 0.0000
U 0 0.000000 0.0000 0.0000
B 3780 3432.000000 155593.4900 105.0500
P 1762 1499.250000 67230.6500 67027.1500
D 46 37.250000 2323.4400 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
1743 1816.750000 92627.8300 0.0000
Other 24 27.500000 1651.3700 177.2500
---------------------------------------------------------
Total 7390 6857.500000 321082.5300 67309.4500
Center 55
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 2974 2390.500000 101758.3200 0.0000
P 415 315.750000 12837.5500 15989.6000
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
3525 3587.083333 218022.5600 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 6914 6293.333333 332618.4300 15989.6000
Center 57
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 8 8.750000 323.7500 0.0000
U 0 0.000000 0.0000 0.0000
B 641 728.250000 27939.3100 148.0000
P 3449 3963.000000 161258.1900 160153.5400
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
1298 4434.750000 222824.5300 222556.2800
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 5396 9134.750000 412345.7800 382857.8200