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:EIP DEI DEIP
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 13418 44397.50000 1641635.8000 36.9759
Subtotal (Total Children Is Unduplicated) 13418 44397.50000 1641635.8000 36.9759
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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 49 75.500000 5662.5000 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 38 56.500000 4208.2500 74.4823
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 2.000000 150.0000 75.0000
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 11 17.000000 1275.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 15 35.000000 2625.0000 75.0000
IPDEF-T1024TLTSGT-F/U PHYC AND DEV EVAL BY EI PROF 33 60.500000 4537.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 11 20.500000 1137.7500 55.5000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 69 107.500000 5910.7500 54.9837
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 105 199.000000 14925.0000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 920 1592.333333 119275.7500 74.9063
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 45 78.500000 5887.5000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 428 668.500000 50137.5000 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 275 464.500000 34762.5000 74.8385
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 183 350.000000 19425.0000 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 1068 1725.500000 95765.2500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 94 183.500000 13723.5000 74.7875
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 395 687.500000 51562.5000 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
OCTH-97166TLGT-OT EVAL MODERATE COMPLEXITY 1 1.000000 51.0500 51.0500
OCTH-97167-OT EVAL HIGH COMPLEXITY 1 1.000000 51.0500 51.0500
PSTH-97161-PT EVAL LOW COMPLEXITY 2 2.000000 102.1000 51.0500
SCREEN-T1023-SCREENING 14 14.000000 700.0000 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 4 4.000000 204.2000 51.0500
SPCH-92523GT-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 1 1.000000 51.0500 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) 2229 6455.333333 439648.7000 68.1063
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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 137 605.000000 30210.0000 49.9339
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 432 1560.000000 77970.0000 49.9808
OCCT-97530-OT SESSION BY LICENSED OT 20 47.000000 3357.6800 71.4400
OCCT-97530GT-OT SESSION BY LICENSED OT 29 73.750000 5268.7000 71.4400
OCCT-97530TL-OT SESSION BY LICENSED OT 4 5.750000 410.7800 71.4400
OCCT-97530TLGT-OT SESSION BY LICENSED OT 94 385.000000 27504.4000 71.4400
PHY-97110-PT SESSION BY LICENSED PT 28 55.000000 3929.2000 71.4400
PHY-97110GT-PT SESSION BY LICENSED PT 28 88.500000 6322.4400 71.4400
PHY-97110TL-PT SESSION BY LICENSED PT 10 15.000000 1071.6000 71.4400
PHY-97110TLGT-PT SESSION BY LICENSED PT 63 262.500000 18753.0000 71.4400
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 35 132.250000 9447.9400 71.4400
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 26 60.250000 4304.2600 71.4400
SPL-92507TL-SPL THERAPY SESSION BY LICENSED SLP 43 240.250000 17163.4600 71.4400
SPL-92507TLGT-SPL THERAPY SESSION BY LICENSED SLP 112 528.500000 37756.0400 71.4400
SPL-92508-GROUP SPL SESSION PER CHILD 2 7.750000 107.5700 13.8800
SPL-92508TLGT-SPL THERAPY SESSION BY LICENSED SLP 1 1.000000 13.8800 13.8800
Subtotal (Total Children Is Unduplicated) 941 4069.000000 243628.4500 59.8743
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Total 54921.833333 2324912.9500 42.3313
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Number of Children (Unduplicated) With at Least One Service 13579
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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 0 0.000000 0.0000 0.0000
D 1 0.250000 9.2500 0.0000
S 3502 2247.250000 100908.1700 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 100 37.750000 1472.7500 0.0000
---------------------------------------------------------
Total 9076 5484.250000 234065.9200 117907.7500
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 71 116.250000 4358.2500 0.0000
U 0 0.000000 0.0000 0.0000
B 2338 3819.000000 149552.2500 0.0000
P 1000 1657.250000 64481.2500 64452.5000
D 91 149.750000 5925.5000 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
418 563.750000 27404.2500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 3918 6306.000000 251721.5000 64452.5000
Center 05
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 3 1.250000 46.2500 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 2691 1917.750000 73358.6600 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
6361 4416.000000 181237.7500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 6361 4416.000000 181237.7500 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 2898 2393.250000 102532.0000 102406.2000
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 3665 3006.500000 127186.7500 102406.2000
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
0 0.000000 0.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 3503 3804.500000 150902.5000 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 6920 5612.500000 233098.0000 235709.6500
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
0 0.000000 0.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 8851 7232.500000 303824.2500 235709.6500
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
274 268.500000 12522.6900 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 285 278.250000 13056.1900 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
1 2.000000 150.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 2204 2282.000000 103998.4500 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
10 7.250000 384.5700 0.0000
Other 19 15.000000 1037.1600 37.0000
---------------------------------------------------------
Total 4558 4157.250000 197106.7000 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
97 96.000000 4555.4500 0.0000
Other 24 27.500000 1651.3700 177.2500
---------------------------------------------------------
Total 5744 5136.750000 233010.1500 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 413 311.750000 12576.5500 15743.6000
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
1 1.333333 100.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 3388 2703.583333 114434.8700 15743.6000
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
6 7.250000 268.2500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 4104 4707.250000 189789.5000 160301.5400