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
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 791 771.250000 28527.0000 36.9880
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 751 861.250000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 538 1946.000000 71992.7500 36.9952
Subtotal (Total Children Is Unduplicated) 1264 3578.500000 100519.7500 28.0899
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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 3 4.500000 337.5000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 2 3.000000 225.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 3 4.000000 300.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 3 3.500000 194.2500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 101 132.613631 9759.5600 73.5939
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 29 36.577700 2743.3300 75.0001
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 38 50.500000 3639.5000 72.0693
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 151 189.500000 10517.2500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 59 90.500000 6787.5000 75.0000
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 3 3.000000 160.6500 53.5500
Subtotal (Total Children Is Unduplicated) 253 523.691331 34964.5400 66.7656
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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 131 125.250000 0.0000 0.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 1 2.000000 100.0000 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
TRAV-TRAVS-Travel by mile 231 7671.000000 3403.2800 0.4437
Subtotal (Total Children Is Unduplicated) 409 8352.250000 12193.7800 1.4599
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Total 12454.441331 147678.0700 11.8575
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Number of Children (Unduplicated) With at Least One Service 1323
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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 58 740.750000 1829.4800 1829.4800
D 4 45.000000 18.7500 0.0000
S 1 16.000000 6.2500 6.2500
H 0 0.000000 0.0000 0.0000
T 4 24.500000 202.8800 202.8800
331 245.250000 7533.2500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 398 1071.500000 9590.6100 2038.6100
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 256 1487.000000 4220.6300 0.0000
---------------------------------------------------------
Total 302 2203.250000 5503.9300 1133.3000
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
440 317.250000 9697.5000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 440 317.250000 9697.5000 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 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
259 271.250000 11509.9000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 259 271.250000 11509.9000 0.0000
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 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 385 880.750000 10161.5900 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
480 337.750000 11375.7500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 483 343.750000 11739.7500 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 0 0.000000 0.0000 0.0000
P 25 53.000000 579.3200 579.3200
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
487 405.000000 12650.7500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 521 469.500000 13816.3200 579.3200
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 345 623.500000 14313.0000 14313.0000
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
3 2.500000 92.5000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 348 626.000000 14405.5000 14313.0000
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 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
250 280.500000 10807.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 256 288.750000 11084.2500 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 0 0.000000 0.0000 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
243 190.750000 6153.2500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 279 226.750000 7609.2500 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 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 83 1291.000000 993.6000 953.3500
273 193.250000 6004.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 356 1484.250000 6997.6000 953.3500
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 33 450.500000 427.7300 427.7300
T 31 240.500000 371.7600 371.7600
594 828.500000 7971.5300 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 658 1519.500000 8771.0200 799.4900
Center 54
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 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 166 1203.500000 2571.5500 2571.5500
T 2 48.000000 30.9200 30.9200
608 518.750000 5364.6000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 776 1770.250000 7967.0700 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 18 76.349200 1241.5300 1241.5300
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
467 346.342131 12233.9100 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 485 422.691331 13475.4400 1241.5300
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 11 443.000000 273.5900 273.5900
107 116.000000 5074.7500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 118 559.000000 5348.3400 273.5900