CMS/EIP Fiscal Report Statewide
Services beginning 10/01/2017 ending 12/31/2017 Date of Report:02/03/2018 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 726 660.500000 24438.5000 37.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 682 748.000000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 540 1985.250000 73380.2500 36.9627
Subtotal (Total Children Is Unduplicated) 1210 3393.750000 97818.7500 28.8232
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Screening, Eval, and Assessment,Class #02
EVAL-96111-DEVELOPMENTAL EVALUATION 1 2.000000 100.0000 50.0000
EXIT-EXIT-EXIT ASSESSMENT 1 1.000000 50.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 3 5.000000 375.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 2 4.000000 300.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 4 6.000000 450.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 4 4.500000 249.7500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 105 153.428933 11313.7000 73.7390
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 32 47.000000 3525.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 22 34.500000 2537.5000 73.5507
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 156 200.500000 11072.2500 55.2232
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 88 127.500000 9378.6400 73.5580
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 15 15.000000 803.2500 53.5500
Subtotal (Total Children Is Unduplicated) 273 600.428933 40155.0900 66.8773
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 1 2.000000 100.0000 50.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 4 7.000000 350.0000 50.0000
CONIP-CONIP-CONSULT, ITDS PHONE 1 1.000000 25.0000 25.0000
DSTT-DSTT-DIRECT SERVICE COORDINATOR TRAVEL 213 279.500000 0.0000 0.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 2 7.000000 350.0000 50.0000
INTR-T1013-INTERPRETER 30 74.250000 3630.0000 48.8889
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 277 574.000000 5740.0000 10.0000
PHY-97110-PT SESSION BY LICENSED PT 1 1.000000 71.4400 71.4400
TRAV-TRAVS-Travel by mile 248 7844.000000 3484.2800 0.4442
Subtotal (Total Children Is Unduplicated) 432 8789.750000 13750.7200 1.5644
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Total 12783.928933 151724.5600 11.8684
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Number of Children (Unduplicated) With at Least One Service 1274
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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 87 692.250000 2886.5400 2886.5400
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
252 192.500000 5911.2500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 339 884.750000 8797.7900 2886.5400
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 44 636.500000 1945.1800 1952.1800
0 0.000000 0.0000 0.0000
Other 222 810.500000 4369.4800 0.0000
---------------------------------------------------------
Total 266 1447.000000 6314.6600 1952.1800
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
428 321.500000 9984.5000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 428 321.500000 9984.5000 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 3 13.000000 130.0000 130.0000
D 4 10.000000 370.0000 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
353 388.750000 17019.5000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 360 411.750000 17519.5000 130.0000
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 85 804.500000 2128.5100 2128.5100
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
135 89.750000 1961.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 220 894.250000 4089.5100 2128.5100
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 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
294 207.500000 6598.7500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 294 207.500000 6598.7500 0.0000
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 21 48.500000 486.8200 486.8200
D 21 27.500000 1462.2500 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
525 445.500000 14290.5000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 567 521.500000 16239.5700 486.8200
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 316 743.500000 13463.4900 13463.4900
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
0 0.000000 0.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 316 743.500000 13463.4900 13463.4900
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
290 335.500000 13405.7500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 290 335.500000 13405.7500 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 11 11.000000 415.5000 415.5000
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 0 0.000000 0.0000 0.0000
93 80.250000 2862.2500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 104 91.250000 3277.7500 415.5000
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 91 1563.500000 1923.4200 1823.4200
293 233.500000 7955.7500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 384 1797.000000 9879.1700 1823.4200
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 81 586.750000 826.1500 826.1500
T 40 441.500000 571.0600 571.0600
695 609.750000 10265.1000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 816 1638.000000 11662.3100 1397.2100
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 77 778.500000 977.0600 977.0600
T 87 754.500000 1281.6700 1271.6700
796 1328.250000 9355.8800 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 960 2861.250000 11614.6100 2248.7300
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 5 10.000000 672.0000 672.0000
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 5 10.000000 672.0000 672.0000
430 342.178933 12357.6700 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 440 362.178933 13701.6700 1344.0000
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 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 11 155.000000 164.5300 164.5300
98 112.000000 5011.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 109 267.000000 5175.5300 164.5300