CMS/EIP Fiscal Report Statewide
Services beginning 07/01/2017 ending 09/30/2017 Date of Report:11/05/2017 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 791 771.250000 28527.0000 36.9880
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 751 861.250000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 1464 5663.250000 209449.7500 36.9840
Subtotal (Total Children Is Unduplicated) 1499 7295.750000 237976.7500 32.6185
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Screening, Eval, and Assessment,Class #02
EVAL-96111-DEVELOPMENTAL EVALUATION 3 5.000000 250.0000 50.0000
EXIT-EXIT-EXIT ASSESSMENT 1 1.000000 50.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 22 35.500000 2662.5000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 7 11.500000 739.0200 64.2626
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 10 15.500000 1162.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 12 17.000000 1221.0000 71.8235
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 20 29.000000 1609.5000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 484 726.500000 54103.0200 74.4708
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 191 272.000000 20260.0000 74.4853
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 167 250.500000 18597.0000 74.2395
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 628 932.500000 51581.4000 55.3152
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 292 430.000000 31995.0400 74.4071
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 6 6.000000 822.2000 137.0333
OCTF-97168-OT RE-EVAL EST PLAN CARE 1 1.000000 51.0500 51.0500
SCREEN-T1023-SCREENING 4 4.000000 200.0000 50.0000
Subtotal (Total Children Is Unduplicated) 964 2737.000000 185304.2300 67.7034
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 2 0.750000 37.5000 50.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 3 9.500000 475.0000 50.0000
DSTT-DSTT-DIRECT SERVICE COORDINATOR TRAVEL 133 128.750000 0.0000 0.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 5 32.000000 1600.0000 50.0000
INTR-T1013-INTERPRETER 35 68.750000 3398.0000 49.4255
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 247 475.000000 4780.0000 10.0632
OCCT-97530-OT SESSION BY LICENSED OT 1 0.750000 53.5800 71.4400
OCCT-97530HM-OT SESSION BY OT ASST 1 3.500000 200.2000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 1 4.000000 285.7600 71.4400
TRAV-TRAVS-Travel by mile 231 7671.000000 3403.2800 0.4437
Subtotal (Total Children Is Unduplicated) 410 8394.000000 14233.3200 1.6957
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Total 18426.750000 437514.3000 23.7434
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Number of Children (Unduplicated) With at Least One Service 1520
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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 364 289.250000 11858.2500 0.0000
P 65 751.250000 2452.7300 2452.7300
D 5 47.000000 129.7500 0.0000
S 61 70.250000 2127.5000 6.2500
H 12 15.000000 1125.0000 0.0000
T 6 28.000000 465.3800 465.3800
337 254.750000 8120.0000 0.0000
Other 2 4.000000 261.0000 0.0000
---------------------------------------------------------
Total 852 1459.500000 26539.6100 2924.3600
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 46 716.250000 1283.3000 1133.3000
0 0.000000 0.0000 0.0000
Other 411 1618.500000 9924.3800 0.0000
---------------------------------------------------------
Total 457 2334.750000 11207.6800 1133.3000
Center 03
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 8 11.000000 407.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 227 175.500000 6493.5000 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
483 359.250000 11251.5000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 718 545.750000 18152.0000 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 17 33.250000 1249.2500 0.0000
P 230 424.250000 17314.7500 17314.7500
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 0 0.000000 0.0000 0.0000
335 336.750000 16342.2000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 582 794.250000 34906.2000 17314.7500
Center 05
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 151 133.750000 5613.7500 0.0000
P 94 670.500000 4121.3400 4121.3400
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
291 210.250000 6040.2500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 536 1014.500000 15775.3400 4121.3400
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 364.0000 364.0000
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
736 618.250000 26313.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 739 624.250000 26677.0000 364.0000
Center 07
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 4 3.500000 129.5000 0.0000
P 388 479.750000 20764.3200 20764.3200
D 9 11.500000 586.2500 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
494 413.250000 12956.0000 0.0000
Other 1 0.250000 9.2500 0.0000
---------------------------------------------------------
Total 896 908.250000 34445.3200 20764.3200
Center 09
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 1 1.500000 112.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 8 11.750000 652.5000 308.2500
P 663 1135.250000 39434.2300 39434.2300
D 5 6.500000 419.2500 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
45 66.000000 4474.2500 0.0000
Other 61 93.500000 7012.5000 0.0000
---------------------------------------------------------
Total 783 1314.500000 52105.2300 39742.4800
Center 10
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 7 4.000000 148.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 362 392.750000 17868.0000 0.0000
P 2 4.000000 120.0000 120.0000
D 4 4.250000 157.2500 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
305 391.500000 18332.5000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 680 796.500000 36625.7500 120.0000
Center 51
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 109 89.000000 3584.5000 0.0000
P 36 36.000000 1456.0000 1456.0000
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
262 209.750000 7578.2500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 407 334.750000 12618.7500 1456.0000
Center 52
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 62 75.750000 4495.5000 0.0000
P 153 166.000000 7316.7500 7316.7500
D 9 15.500000 860.2500 0.0000
S 0 0.000000 0.0000 0.0000
H 19 34.500000 2412.0000 0.0000
T 106 1336.000000 4173.6000 3773.3500
288 221.750000 7939.4600 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 637 1849.500000 27197.5600 11090.1000
Center 53
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 59 51.000000 1887.0000 0.0000
P 249 288.000000 13452.0000 13452.0000
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 33 450.500000 427.7300 427.7300
T 32 242.500000 521.7600 521.7600
684 933.750000 14037.5400 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 1057 1965.750000 30326.0300 14401.4900
Center 54
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 695 664.000000 30090.0000 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 166 1203.500000 2571.5500 2571.5500
T 2 48.000000 30.9200 30.9200
750 698.500000 14761.6000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 1613 2614.000000 47454.0700 2602.4700
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 466 634.349200 26504.5300 26504.5300
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
563 511.400800 24075.8900 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 1031 1149.750000 50880.4200 26504.5300
Center 57
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 1 1.000000 37.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 67 86.250000 3548.7500 0.0000
P 51 58.500000 2625.2500 2625.2500
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 13 447.000000 534.5900 534.5900
113 128.000000 5857.7500 783.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 245 720.750000 12603.3400 3942.8400