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:TPIN
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 11 22.750000 860.2500 37.8132
Subtotal (Total Children Is Unduplicated) 11 22.750000 860.2500 37.8132
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Screening, Eval, and Assessment,Class #02
ASTE-ASTE-ASSISTIVE TECHNOLOGY EVAL 1 1.000000 48.5000 48.5000
EVAL-96111-DEVELOPMENTAL EVALUATION 1 2.000000 100.0000 50.0000
EXIT-EXIT-EXIT ASSESSMENT 1 2.000000 100.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 5 7.000000 525.0000 75.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 16 28.000000 2100.0000 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 2 3.500000 262.5000 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 4 7.500000 562.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 6 10.500000 787.5000 75.0000
IPDEF-T1024TLTSGT-F/U PHYC AND DEV EVAL BY EI PROF 11 14.000000 1050.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 3 4.000000 222.0000 55.5000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 18 33.000000 1831.5000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 74 135.500000 10162.5000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 347 665.760534 49208.0400 73.9125
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 8 14.000000 1050.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 143 273.000000 20430.0000 74.8352
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 29 56.500000 4237.5000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 86 157.500000 11642.5000 73.9206
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 51 90.500000 5022.7500 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 310 578.500000 31545.2900 54.5295
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 33 68.000000 5100.0000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 166 278.000000 20820.7500 74.8948
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 13 13.000000 3952.0000 304.0000
OCTH-97166-OT EVAL MODERATE COMPLEXITY 2 2.000000 102.1000 51.0500
OCTH-97166GT-OT EVAL MODERATE COMPLEXITY 1 1.000000 51.0500 51.0500
OCTH-97166TLGT-OT EVAL MODERATE COMPLEXITY 2 2.000000 102.1000 51.0500
OCTH-97167GT-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-97161-PT EVAL LOW COMPLEXITY 2 2.000000 102.1000 51.0500
PSTH-97163-PT EVAL HIGH COMPLEXITY 1 1.000000 51.0500 51.0500
SCREEN-T1023-SCREENING 5 5.000000 250.0000 50.0000
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 7 8.000000 408.4000 51.0500
SPCH-92523GT-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 1 1.000000 51.0500 51.0500
SPCH-92523TLGT-EVAL OF SPCH SOUND PROD; EVAL LANG COM 1 1.000000 51.0500 51.0500
SPCH-92610-EVAL OF ORAL,PHARYNGEAL SWALLOWING FUNC 1 1.000000 48.9400 48.9400
Subtotal (Total Children Is Unduplicated) 821 2475.260534 172544.3200 69.7075
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EI Services,Class #03
CONPF-CONPF-CONSULT, PT, FACE TO FACE 1 1.000000 50.0000 50.0000
CONPF-CONPFGT-CONSULT,PT,FACE TO FACE 1 1.000000 50.0000 50.0000
DSTT-DSTT-DIRECT SERVICE COORDINATOR TRAVEL 4 3.500000 0.0000 0.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 53 194.250000 9692.5000 49.8970
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 82 301.250000 14992.5000 49.7676
OCCT-97530-OT SESSION BY LICENSED OT 10 25.500000 1821.7200 71.4400
OCCT-97530GT-OT SESSION BY LICENSED OT 75 313.250000 22378.5800 71.4400
OCCT-97530TLGT-OT SESSION BY LICENSED OT 6 40.500000 2893.3200 71.4400
PHY-97110-PT SESSION BY LICENSED PT 27 79.250000 5661.6200 71.4400
PHY-97110GT-PT SESSION BY LICENSED PT 44 185.750000 13269.9800 71.4400
PHY-97110TLGT-PT SESSION BY LICENSED PT 1 5.750000 410.7800 71.4400
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 76 374.250000 25571.5800 68.3275
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 127 426.250000 30210.9400 70.8761
SPL-92507TL-SPL THERAPY SESSION BY LICENSED SLP 2 4.000000 285.7600 71.4400
SPL-92507TLGT-SPL THERAPY SESSION BY LICENSED SLP 7 32.000000 2286.0800 71.4400
SPL-92508-GROUP SPL SESSION PER CHILD 1 1.000000 13.8800 13.8800
Subtotal (Total Children Is Unduplicated) 441 1988.500000 129589.2400 65.1693
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Total 4486.510534 302993.8100 67.5344
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Number of Children (Unduplicated) With at Least One Service 1190
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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 0 0.000000 0.0000 0.0000
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 320 352.000000 22407.9300 0.0000
T 0 0.000000 0.0000 0.0000
134 148.000000 9782.4700 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 454 500.000000 32190.4000 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 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 2 2.500000 162.5000 162.5000
T 0 0.000000 0.0000 0.0000
383 475.000000 34260.8100 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 385 477.500000 34423.3100 162.5000
Center 04
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
82 91.000000 9655.7500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 82 91.000000 9655.7500 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
142 248.000000 17001.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 142 248.000000 17001.0000 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 0 0.000000 0.0000 0.0000
D 1 2.000000 150.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 34 68.000000 5100.0000 0.0000
T 0 0.000000 0.0000 0.0000
59 104.750000 6823.2500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 94 174.750000 12073.2500 0.0000
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 115 150.250000 9183.2700 9595.1300
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 36 58.000000 3603.1600 3171.1600
47 68.500000 4553.0300 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 198 276.750000 17339.4600 12766.2900
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 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
289 645.000000 44348.2500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 289 645.000000 44348.2500 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 49 63.750000 3383.2400 2891.1800
D 88 109.500000 5880.8200 0.0000
S 2 0.750000 27.7500 0.0000
H 83 99.000000 6381.7100 40.0000
T 245 270.500000 16981.7300 11269.9400
60 73.500000 5004.7100 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 527 617.000000 37659.9600 14201.1200
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 3 3.000000 171.4400 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 2 2.000000 105.5000 0.0000
550 617.500000 40411.6100 0.0000
Other 26 26.000000 1621.6000 0.0000
---------------------------------------------------------
Total 581 648.500000 42310.1500 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 10 9.000000 642.9600 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
382 412.250000 29099.8600 0.0000
Other 23 20.750000 1343.0000 0.0000
---------------------------------------------------------
Total 415 442.000000 31085.8200 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 0 0.000000 0.0000 0.0000
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 33 54.500000 3979.7300 0.0000
T 0 0.000000 0.0000 0.0000
26 38.760534 2821.4400 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 59 93.260534 6801.1700 0.0000
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
204 272.750000 18105.2900 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 204 272.750000 18105.2900 0.0000