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
Agency Filter:EXT
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 58 71.250000 2599.2500 36.4807
Subtotal (Total Children Is Unduplicated) 58 71.250000 2599.2500 36.4807
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 5 10.000000 750.0000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 5 10.000000 750.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 1.500000 112.5000 75.0000
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 6 11.000000 786.0000 71.4545
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 1 2.000000 150.0000 75.0000
IPDEF-T1024TLTSGT-F/U PHYC AND DEV EVAL BY EI PROF 4 7.000000 525.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 6 11.500000 638.2500 55.5000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 17 31.000000 1720.5000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 6 12.000000 900.0000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 95 184.000000 13800.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 8 13.000000 975.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 125 242.000000 18150.0000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 78 151.500000 11362.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 23 44.000000 2442.0000 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 243 462.500000 25668.7500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 4 5.500000 412.5000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 62 108.500000 8137.5000 75.0000
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 1 1.000000 51.0500 51.0500
OCTH-97167-OT EVAL HIGH COMPLEXITY 33 33.000000 1684.6500 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-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 11 11.000000 550.0000 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 17 17.000000 867.8500 51.0500
SPCH-92523GT-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 5 5.000000 255.2500 51.0500
SPCH-92523TL-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 8 8.000000 408.4000 51.0500
SPCH-92523TLGT-EVAL OF SPCH SOUND PROD; EVAL LANG COM 1 1.000000 51.0500 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) 742 1460.000000 95079.6000 65.1230
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 5 9.000000 4477.7800 497.5311
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 1 5.000000 125.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 2992 21310.75000 1065488.5000 49.9977
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 1585 8517.250000 425817.5000 49.9947
OCCT-97530-OT SESSION BY LICENSED OT 356 1463.750000 104570.3000 71.4400
OCCT-97530GT-OT SESSION BY LICENSED OT 67 269.500000 19074.4800 70.7773
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 49 245.750000 17556.3800 71.4400
OCCT-97530TLGT-OT SESSION BY LICENSED OT 16 35.000000 2500.4000 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 362 1649.500000 117840.2800 71.4400
PHY-97110GT-PT SESSION BY LICENSED PT 109 344.750000 24586.0600 71.3156
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 34 178.500000 12752.0400 71.4400
PHY-97110TLGT-PT SESSION BY LICENSED PT 3 12.000000 857.2800 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 514 2742.250000 194989.2600 71.1056
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 149 730.750000 52204.7800 71.4400
SPL-92507TL-SPL THERAPY SESSION BY LICENSED SLP 100 436.750000 31201.4200 71.4400
SPL-92507TLGT-SPL THERAPY SESSION BY LICENSED SLP 7 39.750000 2839.7400 71.4400
SPL-92508-GROUP SPL SESSION PER CHILD 5 10.000000 138.8000 13.8800
Subtotal (Total Children Is Unduplicated) 5214 39325.25000 2152794.9000 54.7433
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Total 40856.500000 2250473.7500 55.0824
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Number of Children (Unduplicated) With at Least One Service 5741
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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 1 1.000000 50.0000 50.0000
D 79 80.000000 4132.4400 0.0000
S 1 1.500000 83.2500 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 134 227.500000 15327.0000 0.0000
---------------------------------------------------------
Total 215 310.000000 19592.6900 50.0000
Center 04
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 12 12.000000 444.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 59 48.750000 1766.7500 0.0000
P 16 19.500000 1000.5000 414.5000
D 0 0.000000 0.0000 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
1 5.000000 250.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 1683 5902.250000 298854.4400 414.5000
Center 05
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 1 1.500000 112.5000 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 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 1 1.500000 112.5000 0.0000
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
4628 4325.250000 225130.1100 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 4628 4325.250000 225130.1100 0.0000
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 1 2.000000 74.0000 -74.0000
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 1 2.000000 74.0000 -74.0000
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 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
1779 5931.000000 331839.0500 0.0000
Other 140 276.000000 19003.5000 0.0000
---------------------------------------------------------
Total 1919 6207.000000 350842.5500 0.0000
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 3 10.250000 732.2600 132.5000
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
3368 10204.750000 580993.2500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 3371 10215.000000 581725.5100 132.5000
Center 51
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
538 1572.250000 95953.5300 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 538 1572.250000 95953.5300 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 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
727 1568.500000 97005.9100 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 727 1568.500000 97005.9100 0.0000
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 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
980 1014.750000 52370.2900 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 980 1014.750000 52370.2900 0.0000
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 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
1646 1720.750000 88072.3800 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 1646 1720.750000 88072.3800 0.0000
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 2 4.000000 261.0000 246.0000
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
3524 3585.750000 217922.5600 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 3526 3589.750000 218183.5600 246.0000
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 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
1292 4427.500000 222556.2800 222556.2800
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 1292 4427.500000 222556.2800 222556.2800