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:Program Patients
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 14151 47748.50000 1765511.8000 36.9752
Subtotal (Total Children Is Unduplicated) 14151 47748.50000 1765511.8000 36.9752
-----------------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 9 15.500000 1162.5000 75.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 66 107.000000 8025.0000 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 47 73.500000 5483.2500 74.6020
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 19 33.500000 2473.5000 73.8358
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 17 38.500000 2887.5000 75.0000
IPDEF-T1024TLTSGT-F/U PHYC AND DEV EVAL BY EI PROF 37 72.500000 5437.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 20 38.000000 2109.0000 55.5000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 91 147.500000 8130.7500 55.1237
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 130 241.000000 18075.0000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 1296 2252.170133 168763.5100 74.9337
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 68 115.500000 8662.5000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 705 1159.122000 86934.1500 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 39 74.000000 5550.0000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 453 781.500000 58537.5000 74.9040
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 252 473.000000 26251.5000 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 1614 2675.000100 148462.5055 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 117 220.500000 16498.5000 74.8231
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 553 963.500000 72262.5000 75.0000
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 15 15.000000 883.6500 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) 2988 9693.792233 656767.1255 67.7513
-----------------------------------------------------------------------------------------------------------------------
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 3131 21919.75000 1095898.5000 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:Program Patients
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Subtotal (Total Children Is Unduplicated) 6090 43398.25000 2396623.3500 55.2240
-----------------------------------------------------------------------------------------------------------------------
Total 100840.542233 4818902.2755 47.7873
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 15302
-----------------------------------------------------------------------------------------------------------------------
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 3688 2419.250000 109400.4200 0.0000
H 5670 3386.250000 139900.2500 125725.2500
T 1 0.250000 9.2500 0.0000
21 7.500000 277.5000 0.0000
Other 283 314.000000 19821.7500 0.0000
---------------------------------------------------------
Total 9752 6210.500000 273674.8600 125775.2500
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 1226 933.250000 42902.2500 0.0000
---------------------------------------------------------
Total 1226 933.250000 42902.2500 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 3664 2743.250000 116992.6700 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 3783 2841.250000 121866.0100 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 97 160.250000 6314.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 1598 5821.000000 295593.1900 0.0000
T 0 0.000000 0.0000 0.0000
445 604.750000 29601.9100 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 5789 12515.750000 563762.3500 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 2821 2048.250000 78415.1600 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
3 1.750000 64.7500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 2829 2053.750000 78713.6600 13449.5050
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
11384 9139.250000 424978.1100 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 11384 9139.250000 424978.1100 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 733 599.500000 23677.0000 0.0000
P 3005 2533.250000 109216.0000 108942.2000
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
59 37.500000 1463.5000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 3812 3191.750000 135773.0000 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 8 22.500000 980.5000 592.0000
1791 5955.000000 333639.0500 0.0000
Other 188 367.000000 25575.0000 0.0000
---------------------------------------------------------
Total 5598 10329.250000 519356.8000 126029.7500
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 89 111.500000 6975.2500 0.0000
S 114 209.500000 14298.7500 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 12635 17939.500000 909892.0100 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
833 1858.750000 109301.4700 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 854 1877.000000 110404.2200 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 2 2.000000 70.0000 0.0000
S 279 289.750000 12483.4600 188.8000
H 9 9.000000 581.5200 0.0000
T 0 0.000000 0.0000 0.0000
744 1601.500000 99285.9100 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 3056 4052.250000 211527.1100 74044.4800
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 69 71.500000 3999.3500 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
995 1031.500000 53360.1100 0.0000
Other 20 16.000000 1092.6600 37.0000
---------------------------------------------------------
Total 5894 5554.750100 267848.7455 62217.6400
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 52 48.250000 3148.4400 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
1773 1867.750000 95763.5800 0.0000
Other 25 29.500000 1801.3700 177.2500
---------------------------------------------------------
Total 7810 7367.000000 345393.2800 75636.4500
Center 55
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 3404 2934.500000 127662.3200 0.0000
P 484 400.750000 16514.5500 37928.8500
D 0 0.000000 0.0000 0.0000
S 1 0.836800 62.7600 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
3617 3768.955333 230288.4600 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 7506 7105.042133 374528.0900 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
1298 4434.750000 222824.5300 222556.2800
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 5774 9730.250000 438281.7800 401826.4700