CMS/EIP Fiscal Report Statewide
Services beginning 04/01/2018 ending 06/30/2018 Date of Report:08/09/2018 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 836 952.250000 35233.2500 37.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 702 765.500000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 540 2099.750000 77681.5000 36.9956
Subtotal (Total Children Is Unduplicated) 1271 3817.500000 112914.7500 29.5782
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Screening, Eval, and Assessment,Class #02
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 10 10.000000 82.6000 8.2600
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 11 11.000000 278.4100 25.3100
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 3 3.000000 55.6500 18.5500
EXIT-EXIT-EXIT ASSESSMENT 3 3.000000 150.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 5 7.122000 534.1500 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 2 2.500000 187.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 1 2.000000 150.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 5 7.500000 416.2500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 142 202.241732 14992.1900 74.1301
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 63 96.783333 7258.7500 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 43 67.500000 5062.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 198 260.000000 14369.0000 55.2654
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 59 84.000000 6300.0000 75.0000
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 17 17.000000 910.3500 53.5500
SCREEN-T1023-SCREENING 6 8.000000 400.0000 50.0000
Subtotal (Total Children Is Unduplicated) 327 781.647065 51147.3500 65.4354
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 1 1.000000 50.0000 50.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 2 2.000000 100.0000 50.0000
DSTT-DSTT-DIRECT SERVICE COORDINATOR TRAVEL 201 202.750000 0.0000 0.0000
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 1 3.250000 81.2500 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 1 2.000000 100.0000 50.0000
INTR-T1013-INTERPRETER 27 60.250000 2845.0000 47.2199
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 293 549.000000 5480.0000 9.9818
PHY-97110-PT SESSION BY LICENSED PT 1 4.000000 285.7600 71.4400
TRAV-TRAVS-Travel by mile 254 8010.000000 3553.4400 0.4436
Subtotal (Total Children Is Unduplicated) 433 8834.250000 12495.4500 1.4144
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Total 13433.397065 176557.5500 13.1432
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Number of Children (Unduplicated) With at Least One Service 1338
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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 41 344.500000 1482.8400 1482.8400
D 1 3.000000 111.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 31 221.250000 1189.5300 1189.5300
302 232.000000 7323.2500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 375 800.750000 10106.6200 2672.3700
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 37 777.500000 1259.5000 1259.5000
0 0.000000 0.0000 0.0000
Other 269 1205.000000 3951.7500 0.0000
---------------------------------------------------------
Total 306 1982.500000 5211.2500 1259.5000
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
430 387.750000 16686.5000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 430 387.750000 16686.5000 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
345 371.500000 15295.6900 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 345 371.500000 15295.6900 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 139 1561.500000 4658.8400 4658.3400
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
242 210.750000 4550.3000 17.8000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 381 1772.250000 9209.1400 4676.1400
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 5 6.000000 140.0000 140.0000
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
358 270.250000 8759.5000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 363 276.250000 8899.5000 140.0000
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 49 118.500000 1357.5100 1357.5100
D 0 0.000000 0.0000 0.0000
S 6 12.000000 900.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
399 302.750000 9785.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 454 433.250000 12042.5100 1357.5100
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 473 875.000000 19711.6600 19711.6600
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 1 1.500000 83.2500 0.0000
---------------------------------------------------------
Total 474 876.500000 19794.9100 19711.6600
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
315 317.750000 11486.5000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 315 317.750000 11486.5000 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 67 67.000000 2764.5700 2764.5700
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
347 279.500000 9499.7500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 414 346.500000 12264.3200 2764.5700
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 59 961.500000 578.0700 563.0700
226 174.250000 6021.7500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 285 1135.750000 6599.8200 563.0700
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 2 2.250000 83.2500 0.0000
H 18 103.000000 141.4000 141.4000
T 34 387.500000 722.0200 722.0200
661 786.250000 12105.2200 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 715 1279.000000 13051.8900 863.4200
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 9 14.000000 594.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 83 776.000000 957.4000 957.4000
T 80 664.250000 900.9000 900.9000
739 1266.750000 10984.3300 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 911 2721.000000 13436.6300 1858.3000
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 38 109.567732 3778.2900 3778.2900
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 1 2.000000 150.0000 0.0000
T 0 0.000000 0.0000 0.0000
437 296.829333 11132.9500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 476 408.397065 15061.2400 3778.2900
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 2 2.000000 130.5000 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 9 153.000000 144.5300 144.5300
147 169.250000 7136.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 158 324.250000 7411.0300 144.5300