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
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 766 706.250000 26122.0000 36.9869
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 749 1115.750000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 553 2047.000000 75692.7500 36.9774
Subtotal (Total Children Is Unduplicated) 1247 3869.000000 101814.7500 26.3155
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Screening, Eval, and Assessment,Class #02
EVAL-96111-DEVELOPMENTAL EVALUATION 40 106.750000 5337.5000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 5 8.000000 600.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 2.000000 150.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 1.500000 112.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 2 4.000000 300.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 9 12.500000 635.4700 50.8376
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 152 231.019333 16628.0100 71.9767
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 50 68.500000 4777.8300 69.7493
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 48 74.000000 5286.8900 71.4445
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 209 305.500000 16626.6300 54.4243
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 96 160.000000 11691.8000 73.0738
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 4 4.000000 162.0000 40.5000
SCREEN-T1023-SCREENING 2 3.000000 150.0000 50.0000
Subtotal (Total Children Is Unduplicated) 379 980.769333 62458.6300 63.6833
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EI Services,Class #03
INTR-T1013-INTERPRETER 43 86.750000 4494.0000 51.8040
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 244 450.000000 4510.0000 10.0222
TRAV-TRAVS-Travel by mile 201 5713.000000 2533.1100 0.4434
Subtotal (Total Children Is Unduplicated) 371 6249.750000 11537.1100 1.8460
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Total 11099.519333 175810.4900 15.8395
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Number of Children (Unduplicated) With at Least One Service 1324
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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 78 703.000000 3946.2300 3946.2300
D 15 92.000000 652.2400 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 2 26.500000 94.2000 94.2000
469 382.750000 12594.2500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 564 1204.250000 17286.9200 4040.4300
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 256 406.250000 3722.3400 0.0000
---------------------------------------------------------
Total 314 1758.250000 6388.0600 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 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
486 482.750000 20688.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 486 482.750000 20688.0000 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 2 3.000000 30.0000 30.0000
D 3 8.500000 314.5000 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
176 161.750000 6936.7500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 181 173.250000 7281.2500 30.0000
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 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 323 788.250000 8823.7400 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
341 238.000000 7785.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 344 244.000000 8162.0000 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 0 0.000000 0.0000 0.0000
P 45 71.500000 1286.0800 1286.0800
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
648 618.250000 15251.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 704 701.750000 16981.0800 1286.0800
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 394 474.000000 14749.0600 14749.0600
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
47 54.500000 2266.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 441 528.500000 17015.0600 14749.0600
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
429 442.250000 16676.7500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 429 442.250000 16676.7500 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 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
173 112.750000 3823.2500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 190 130.250000 4308.7500 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 0 0.000000 0.0000 0.0000
P 1 2.000000 83.2500 83.2500
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 106 1315.500000 2502.2000 2499.2000
175 148.000000 4803.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 282 1465.500000 7388.4500 2582.4500
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 0 0.000000 0.0000 0.0000
T 13 106.000000 328.1700 328.1700
474 521.250000 9155.1200 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 487 627.250000 9483.2900 328.1700
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 74 541.500000 1562.0500 1562.0500
T 79 646.000000 1690.7400 1690.7400
780 732.750000 12107.3700 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 933 1920.250000 15360.1600 3252.7900
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 32 48.000000 2354.0000 2354.0000
D 8 16.000000 1200.0000 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
345 243.269333 8726.7000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 385 307.269333 12280.7000 2354.0000
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 4 4.000000 40.0000 40.0000
H 0 0.000000 0.0000 0.0000
T 5 151.000000 345.5300 345.5300
150 170.750000 7300.7500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 159 325.750000 7686.2800 385.5300