CMS/EIP Fiscal Report Statewide
Services beginning 07/01/2016 ending 09/30/2016 Date of Report:10/31/2016 Page: 1
List order: No List
Payclass Filters:GR
Eligibility Filter:Not Part C
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
CASE-CASE-NON-TCM CASE MANAGEMENT 694 706.500000 26105.5000 36.9505
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 656 914.250000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 495 1741.750000 64370.7500 36.9575
Subtotal (Total Children Is Unduplicated) 1125 3362.500000 90476.2500 26.9074
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Screening, Eval, and Assessment,Class #02
EVAL-96111-DEVELOPMENTAL EVALUATION 23 52.000000 2600.0000 50.0000
EXIT-EXIT-EXIT ASSESSMENT 2 4.000000 200.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 3 4.500000 337.5000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 4 6.000000 450.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 3 3.500000 212.5000 60.7143
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 4 7.500000 416.2500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 113 168.509600 12048.1500 71.4983
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 42 55.000000 3984.0400 72.4371
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 34 43.500000 3262.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 180 244.000000 13326.1500 54.6154
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 69 98.500000 7258.0000 73.6853
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 2 2.000000 81.0000 40.5000
SCREEN-T1023-SCREENING 7 10.000000 500.0000 50.0000
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 3 3.000000 153.1500 51.0500
Subtotal (Total Children Is Unduplicated) 308 702.009600 44829.2400 63.8584
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EI Services,Class #03
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 1 1.000000 25.0000 25.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 3 3.250000 162.5000 50.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 1 2.000000 100.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 1 8.000000 400.0000 50.0000
INTR-T1013-INTERPRETER 31 52.750000 2718.5000 51.5355
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 223 399.000000 4020.0000 10.0752
PHY-97110-PT SESSION BY LICENSED PT 1 1.000000 71.4400 71.4400
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 1 1.000000 71.4400 71.4400
TRAV-TRAVS-Travel by mile 148 4751.000000 2112.8400 0.4447
Subtotal (Total Children Is Unduplicated) 314 5219.000000 9681.7200 1.8551
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Total 9283.509600 144987.2100 15.6177
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Number of Children (Unduplicated) With at Least One Service 1182
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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 23 84.500000 598.9500 598.9500
D 4 4.000000 160.0000 0.0000
S 6 8.000000 296.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 65 874.500000 3449.4700 3244.0400
368 297.500000 9400.2500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 466 1268.500000 13904.6700 3842.9900
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 53 908.250000 2324.1600 1491.2600
27 304.000000 1370.7800 0.0000
Other 259 180.750000 4108.5900 0.0000
---------------------------------------------------------
Total 339 1393.000000 7803.5300 1491.2600
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 1 2.000000 74.0000 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
469 369.500000 14343.7500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 470 371.500000 14417.7500 0.0000
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 1 1.000000 75.0000 75.0000
D 2 3.000000 111.0000 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
232 262.750000 11679.6500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 235 266.750000 11865.6500 75.0000
Center 05
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 40 346.500000 1062.5800 1062.5800
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
249 343.000000 5055.8400 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 289 689.500000 6118.4200 1062.5800
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 2 4.000000 247.0000 247.0000
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
203 143.500000 5067.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 205 147.500000 5314.0000 247.0000
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 40 43.500000 1083.2500 1083.2500
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
564 458.250000 13576.5000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 604 501.750000 14659.7500 1083.2500
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 333 342.750000 12797.2700 12797.2700
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 11 83.500000 1192.7600 1192.7600
200 211.000000 7913.0000 459.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 544 637.250000 21903.0300 14449.0300
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
217 200.000000 5873.7500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 217 200.000000 5873.7500 0.0000
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 12 12.000000 345.0000 345.0000
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
156 116.500000 3905.5000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 168 128.500000 4250.5000 345.0000
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 106 1140.000000 2332.4500 2271.4500
145 123.500000 3926.2500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 251 1263.500000 6258.7000 2271.4500
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 11 46.000000 87.3700 87.3700
T 0 0.000000 0.0000 0.0000
441 592.750000 5792.2900 0.0000
Other 1 1.000000 10.0000 0.0000
---------------------------------------------------------
Total 453 639.750000 5889.6600 87.3700
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 41 318.250000 552.9700 552.9700
T 0 0.000000 0.0000 0.0000
574 629.500000 9227.3300 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 615 947.750000 9780.3000 552.9700
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 15 29.000000 1771.0000 1771.0000
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 2 4.000000 300.0000 0.0000
T 0 0.000000 0.0000 0.0000
245 205.009600 8183.9700 4584.9700
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 262 238.009600 10254.9700 6355.9700
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 15 449.000000 616.0300 616.0300
126 141.250000 6076.5000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 141 590.250000 6692.5300 616.0300