CMS/EIP Fiscal Report Statewide
Services beginning 01/01/2021 ending 03/31/2021 Date of Report:05/04/2021 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 14438 48732.00000 1802327.5000 36.9845
Subtotal (Total Children Is Unduplicated) 14438 48732.00000 1802327.5000 36.9845
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 25 45.500000 3412.5000 75.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 49 85.000000 6375.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 4 6.000000 450.0000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 26 41.500000 3112.5000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 4 7.500000 562.5000 75.0000
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 27 52.500000 3937.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 20 37.500000 2812.5000 75.0000
IPDEF-T1024TLTSGT-F/U PHYC AND DEV EVAL BY EI PROF 29 55.500000 4162.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 16 30.500000 1692.7500 55.5000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 54 85.500000 4745.2500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 164 305.500000 22873.5000 74.8723
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 936 1643.166666 123070.8000 74.8985
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 43 80.500000 6037.5000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 557 877.000000 65775.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 44 79.000000 5925.0000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 283 488.500000 36562.5000 74.8465
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 212 404.000000 22422.0000 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 1233 2012.500000 111666.0000 55.4862
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 108 203.000000 15225.0000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 420 678.000000 50811.0000 74.9425
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 13 13.000000 765.8300 58.9100
OCTH-97165GT-OT EVAL LOW COMPLEXITY 1 1.000000 51.0500 51.0500
PSTF-97164-PT RE-EVAL EST PLAN CARE 1 1.000000 51.0500 51.0500
PSTH-97161GT-PT EVAL LOW COMPLEXITY 1 1.000000 51.0500 51.0500
PSTH-97162-PT EVAL MODERATE COMPLEXITY 1 1.000000 51.0500 51.0500
PSTH-97163-PT EVAL HIGH COMPLEXITY 4 5.000000 255.2500 51.0500
PSTH-97163GT-PT EVAL HIGH COMPLEXITY 1 2.000000 102.1000 51.0500
PSTH-97163TL-PT EVAL HIGH COMPLEXITY 1 1.000000 51.0500 51.0500
PSTH-97163TLGT-PT EVAL HIGH COMPLEXITY 2 3.000000 153.1500 51.0500
SCREEN-T1023-SCREENING 12 12.000000 600.0000 50.0000
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 9 9.000000 459.4500 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 3 3.000000 153.1500 51.0500
SPCH-92610-EVAL OF ORAL,PHARYNGEAL SWALLOWING FUNC 2 2.000000 89.1000 44.5500
SPCH-92610TL-EVAL OF ORAL,PHARYNGEAL SWALLOWING FUNC 1 1.000000 44.5500 44.5500
SPCH-92610TLGT-EVAL OF ORAL,PHARYNGEAL SWALLOWING FUN 1 1.000000 44.5500 44.5500
Subtotal (Total Children Is Unduplicated) 2460 7282.166666 494962.0800 67.9691
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 190 917.750000 45887.5000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 501 1768.000000 88385.0000 49.9915
OCCT-97530-OT SESSION BY LICENSED OT 21 39.500000 2821.8800 71.4400
OCCT-97530GT-OT SESSION BY LICENSED OT 41 115.000000 8215.6000 71.4400
OCCT-97530TL-OT SESSION BY LICENSED OT 18 38.250000 2732.5800 71.4400
OCCT-97530TLGT-OT SESSION BY LICENSED OT 103 355.750000 25414.7800 71.4400
PHY-97110-PT SESSION BY LICENSED PT 24 30.750000 2196.7800 71.4400
PHY-97110GT-PT SESSION BY LICENSED PT 22 39.250000 2804.0200 71.4400
PHY-97110TL-PT SESSION BY LICENSED PT 24 58.500000 4179.2400 71.4400
PHY-97110TLGT-PT SESSION BY LICENSED PT 75 298.250000 21306.9800 71.4400
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 47 121.000000 8576.8000 70.8826
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 29 57.500000 4107.8000 71.4400
SPL-92507TL-SPL THERAPY SESSION BY LICENSED SLP 67 356.750000 25486.2200 71.4400
SPL-92507TLGT-SPL THERAPY SESSION BY LICENSED SLP 112 521.500000 37234.5200 71.3989
Subtotal (Total Children Is Unduplicated) 1064 4717.750000 279349.7000 59.2125
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Total 60731.916666 2576639.2800 42.4264
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Number of Children (Unduplicated) With at Least One Service 14606
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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 1 1.000000 71.4400 0.0000
S 5904 3774.500000 166662.7700 0.0000
H 4118 2412.750000 100432.6100 100414.1100
T 1 0.250000 9.2500 0.0000
14 5.750000 212.7500 0.0000
Other 56 22.250000 1011.7500 0.0000
---------------------------------------------------------
Total 10094 6216.500000 268400.5700 100414.1100
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 1263 989.250000 44386.2500 0.0000
---------------------------------------------------------
Total 1263 989.250000 44386.2500 0.0000
Center 03
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 22 23.500000 882.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 4215 3007.000000 127861.2600 0.0000
P 224 187.750000 8548.8900 8548.8900
D 5 5.000000 336.8100 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
13 13.750000 905.0700 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 4479 3237.000000 138534.5300 8548.8900
Center 04
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 103 148.000000 6175.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 1716 2862.250000 112649.7500 64.7500
P 1956 3282.500000 121572.7500 120459.4700
D 24 40.000000 1480.0000 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
505 589.250000 37426.8300 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 4304 6922.000000 279304.3300 120524.2200
Center 05
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 16 10.750000 439.9000 0.0000
U 0 0.000000 0.0000 0.0000
B 3030 2006.500000 76397.5200 52349.3600
P 0 0.000000 0.0000 0.0000
D 1 0.750000 27.7500 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
1 1.000000 37.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 3048 2019.000000 76902.1700 52349.3600
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
6270 4464.500000 181922.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 6270 4464.500000 181922.0000 0.0000
Center 07
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 39 38.000000 1519.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 411 327.500000 12679.2500 0.0000
P 3732 3012.250000 127062.7500 127813.3100
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
2 1.500000 55.5000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 4184 3379.250000 141316.5000 127813.3100
Center 09
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 8 10.750000 397.7500 0.0000
U 0 0.000000 0.0000 0.0000
B 142 142.500000 5693.3000 18.5000
P 3348 3638.250000 145157.8000 145657.3000
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 3 3.500000 129.5000 259.0000
0 0.000000 0.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 3501 3795.000000 151378.3500 145934.8000
Center 10
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 67 51.500000 1942.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 2722 2062.500000 79751.0000 18.5000
P 7842 6431.000000 268270.5000 267769.4900
D 57 43.000000 2024.0000 411.0000
S 88 171.500000 11556.0000 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 2 0.500000 18.5000 18.5000
---------------------------------------------------------
Total 10778 8760.000000 363562.5000 268217.4900
Center 51
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 90 89.500000 5267.0000 0.0000
P 2 3.000000 150.0000 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
334 358.250000 14676.9700 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 426 450.750000 20093.9700 0.0000
Center 52
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 4 4.250000 187.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 310 337.000000 18788.1000 0.0000
P 2310 2221.500000 98434.0600 98318.8200
D 1 1.000000 50.0000 0.0000
S 310 327.000000 13825.5000 9.2500
H 15 15.000000 985.8400 71.4400
T 0 0.000000 0.0000 0.0000
4 5.000000 298.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 2954 2910.750000 132568.5000 98399.5100
Center 53
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 20 15.500000 711.2600 0.0000
U 0 0.000000 0.0000 0.0000
B 2645 2398.000000 115641.7400 0.0000
P 2111 1860.250000 88710.3500 88710.3500
D 213 162.250000 8437.9400 0.0000
S 77 61.000000 2680.7600 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 11 9.250000 379.2500 92.5000
---------------------------------------------------------
Total 5077 4506.250000 216561.3000 88802.8500
Center 54
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 8 7.000000 272.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 3162 2767.500000 127226.3200 0.0000
P 2790 2396.000000 107029.4600 107010.9600
D 119 115.750000 5091.6700 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 2.000000 150.0000 0.0000
Other 22 19.750000 1149.1500 101.7500
---------------------------------------------------------
Total 6102 5308.000000 240918.6000 107112.7100
Center 55
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 3868 3167.250000 134330.7300 0.0000
P 207 159.000000 6339.0000 6237.2620
D 0 0.000000 0.0000 0.0000
S 3 4.666666 274.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
2 2.250000 120.2500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 4080 3333.166666 141063.9800 6237.2620
Center 57
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 6 6.500000 257.7200 0.0000
U 0 0.000000 0.0000 0.0000
B 146 167.750000 6724.2900 0.0000
P 3461 4266.250000 172743.7200 170882.0200
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 3613 4440.500000 179725.7300 170882.0200