CMS/EIP Fiscal Report Statewide
Services beginning 10/01/2016 ending 12/31/2016 Date of Report:02/04/2017 Page: 1
List order: No List
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 766 706.750000 26140.5000 36.9869
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 750 1117.250000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 1455 5682.000000 209985.2500 36.9562
Subtotal (Total Children Is Unduplicated) 1485 7506.000000 236125.7500 31.4583
-----------------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
EVAL-96111-DEVELOPMENTAL EVALUATION 41 110.750000 6965.5000 62.8939
EXIT-EXIT-EXIT ASSESSMENT 1 2.000000 100.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 23 38.666667 2900.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 12 19.500000 1462.5000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 8 13.500000 1012.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 19 32.000000 2400.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 34 56.000000 3049.7200 54.4593
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 597 930.833333 68883.7300 74.0022
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 221 323.500000 23757.5000 73.4389
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 168 257.500000 18834.6500 73.1443
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 687 1063.000000 58584.6300 55.1125
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 310 486.000000 36129.3000 74.3401
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 8 8.000000 587.5000 73.4375
SCREEN-T1023-SCREENING 9 10.000000 500.0000 50.0000
Subtotal (Total Children Is Unduplicated) 1122 3351.250000 225167.5300 67.1891
-----------------------------------------------------------------------------------------------------------------------
EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 4 16.000000 800.0000 50.0000
INTR-T1013-INTERPRETER 43 86.750000 4494.0000 51.8040
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 244 450.000000 4510.0000 10.0222
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 1 5.000000 357.2000 71.4400
TRAV-TRAVS-Travel by mile 203 5751.000000 2550.0200 0.4434
Subtotal (Total Children Is Unduplicated) 371 6308.750000 12711.2200 2.0149
-----------------------------------------------------------------------------------------------------------------------
Total 17166.000000 474004.5000 27.6130
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 1514
-----------------------------------------------------------------------------------------------------------------------
Center 01
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 3 1.500000 55.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 362 282.000000 10455.0000 0.0000
P 79 704.500000 4029.4800 4029.4800
D 51 145.000000 4110.4900 0.0000
S 87 107.250000 5572.5000 0.0000
H 8 11.000000 825.0000 0.0000
T 2 26.500000 94.2000 94.2000
474 387.750000 12825.5000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 1066 1665.500000 37967.6700 4123.6800
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 56 1194.000000 2595.4100 2595.4100
2 158.000000 70.3100 0.0000
Other 433 557.750000 10333.5900 0.0000
---------------------------------------------------------
Total 491 1909.750000 12999.3100 2595.4100
Center 03
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 2 2.250000 83.2500 0.0000
P 270 259.250000 12266.7500 6884.2500
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 2 2.000000 1528.0000 0.0000
T 0 0.000000 0.0000 0.0000
486 482.750000 20688.0000 0.0000
Other 5 6.000000 222.0000 0.0000
---------------------------------------------------------
Total 765 752.250000 34788.0000 6884.2500
Center 04
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 3 7.750000 286.7500 0.0000
P 239 407.500000 17520.2500 17623.3700
D 3 8.500000 314.5000 0.0000
S 0 0.000000 0.0000 0.0000
H 2 3.000000 150.0000 0.0000
T 0 0.000000 0.0000 0.0000
205 188.750000 8981.2500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 452 615.500000 27252.7500 17623.3700
Center 05
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 178 159.500000 7497.5000 0.0000
P 96 617.500000 3852.9900 3852.9900
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
227 170.750000 4970.7500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 501 947.750000 16321.2400 3852.9900
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 3 6.000000 377.0000 377.0000
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
563 492.250000 20973.5000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 566 498.250000 21350.5000 377.0000
Center 07
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 15 13.000000 481.0000 0.0000
P 600 666.000000 29132.3300 29132.3300
D 11 12.000000 444.0000 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
652 621.750000 15456.5000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 1278 1312.750000 45513.8300 29132.3300
Center 09
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 11 17.750000 770.7500 0.0000
P 645 848.500000 33096.8100 33096.8100
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
93 120.000000 6903.0000 0.0000
Other 42 58.500000 4387.5000 0.0000
---------------------------------------------------------
Total 791 1044.750000 45158.0600 33096.8100
Center 10
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 4 3.250000 120.2500 0.0000
U 0 0.000000 0.0000 0.0000
B 611 650.500000 30530.2500 0.0000
P 0 0.000000 0.0000 0.0000
D 0 0.000000 0.0000 0.0000
S 14 13.000000 481.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
506 578.250000 25835.5000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 1135 1245.000000 56967.0000 0.0000
Center 51
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 3 3.250000 120.2500 0.0000
U 0 0.000000 0.0000 0.0000
B 128 105.500000 4314.0000 0.0000
P 16 16.000000 430.0000 430.0000
D 1 1.500000 55.5000 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
196 138.250000 5696.7500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 344 264.500000 10616.5000 430.0000
Center 52
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 56 98.000000 6167.7500 0.0000
P 177 212.000000 8982.7600 8849.9700
D 6 11.000000 649.5000 0.0000
S 2 4.000000 300.0000 0.0000
H 1 2.000000 150.0000 0.0000
T 106 1315.500000 2502.2000 2499.2000
234 259.750000 12117.5900 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 582 1902.250000 30869.8000 11349.1700
Center 53
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 4 6.000000 391.5000 0.0000
P 117 144.500000 6572.5000 6572.5000
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 13 106.000000 328.1700 328.1700
545 616.250000 14537.6200 0.0000
Other 1 1.500000 112.5000 0.0000
---------------------------------------------------------
Total 680 874.250000 21942.2900 6900.6700
Center 54
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 487 490.500000 21800.5000 0.0000
P 49 62.250000 4090.7500 4090.7500
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 74 541.500000 1562.0500 1562.0500
T 79 646.000000 1690.7400 1690.7400
891 908.250000 20045.2800 4405.6600
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 1580 2648.500000 49189.3200 11749.2000
Center 55
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 9 10.500000 388.5000 0.0000
P 411 552.000000 25790.0000 25790.0000
D 8 16.000000 1200.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 7 14.000000 1050.0000 0.0000
T 0 0.000000 0.0000 0.0000
429 391.250000 18858.4500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 864 983.750000 47286.9500 25790.0000
Center 57
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 94 119.000000 5722.0000 0.0000
P 31 46.500000 1720.5000 1720.5000
D 0 0.000000 0.0000 0.0000
S 4 4.000000 40.0000 40.0000
H 0 0.000000 0.0000 0.0000
T 5 151.000000 345.5300 345.5300
156 180.750000 7953.2500 522.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 290 501.250000 15781.2800 2628.0300