CMS/EIP Fiscal Report Statewide
Services beginning 10/01/2020 ending 12/31/2020 Date of Report:01/23/2021 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 647 801.750000 29582.0000 36.8968
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 31 25.000000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 1186 5537.000000 204656.2500 36.9616
Subtotal (Total Children Is Unduplicated) 1209 6363.750000 234238.2500 36.8082
-----------------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
EVAL-96111-DEVELOPMENTAL EVALUATION 3 5.500000 275.0000 50.0000
EVAL-96111GT-DEVELOPMENTAL EVALUATION 1 2.000000 100.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 3 6.000000 450.0000 75.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 25 43.000000 3213.1600 74.7247
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 8 13.500000 1012.5000 75.0000
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 8 14.500000 1087.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 1 1.500000 112.5000 75.0000
IPDEF-T1024TLTSGT-F/U PHYC AND DEV EVAL BY EI PROF 7 13.000000 975.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 5 9.000000 499.5000 55.5000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 20 33.000000 1651.1300 50.0342
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 47 77.500000 5762.5000 74.3548
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 509 853.000000 63760.0000 74.7479
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 25 39.500000 2962.5000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 272 446.000000 33450.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 15 23.000000 1725.0000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 177 295.000000 21965.0000 74.4576
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 90 154.000000 8547.0000 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 520 863.000000 47796.5000 55.3841
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 27 46.500000 3487.5000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 182 303.000000 22725.0000 75.0000
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 10 10.000000 834.1900 83.4190
SCREEN-T1023-SCREENING 2 2.000000 100.0000 50.0000
Subtotal (Total Children Is Unduplicated) 979 3253.500000 222491.4800 68.3853
-----------------------------------------------------------------------------------------------------------------------
EI Services,Class #03
DSTT-DSTT-DIRECT SERVICE COORDINATOR TRAVEL 11 16.500000 0.0000 0.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 4 10.000000 500.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 1 3.000000 150.0000 50.0000
INTR-T1013-INTERPRETER 16 26.250000 1312.5000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 26 40.000000 400.0000 10.0000
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 1 2.000000 142.8800 71.4400
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 1 1.500000 107.1600 71.4400
TRAV-TRAVS-Travel by mile 31 711.000000 316.3300 0.4449
Subtotal (Total Children Is Unduplicated) 77 810.250000 2928.8700 3.6148
-----------------------------------------------------------------------------------------------------------------------
Total 10427.500000 459658.6000 44.0814
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 1244
-----------------------------------------------------------------------------------------------------------------------
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 16 23.750000 1470.7500 1470.7500
D 3 2.750000 163.1600 0.0000
S 187 171.500000 8446.0000 0.0000
H 236 211.250000 9634.2500 7817.5000
T 15 40.250000 1255.2000 1255.2000
304 245.000000 10938.0000 0.0000
Other 53 50.500000 3124.7500 0.0000
---------------------------------------------------------
Total 814 745.000000 35032.1100 10543.4500
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 11 296.000000 628.1600 628.1600
0 0.000000 0.0000 0.0000
Other 260 206.750000 9765.7500 0.0000
---------------------------------------------------------
Total 271 502.750000 10393.9100 628.1600
Center 03
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 135 180.000000 8091.2500 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
281 329.250000 17146.7500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 416 509.250000 25238.0000 0.0000
Center 04
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 4 7.000000 259.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 121 199.500000 8409.7500 0.0000
P 33 66.500000 2381.5000 2381.5000
D 6 10.500000 388.5000 0.0000
S 0 0.000000 0.0000 0.0000
H 3 4.000000 200.0000 0.0000
T 0 0.000000 0.0000 0.0000
169 179.750000 8807.4400 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 336 467.250000 20446.1900 2381.5000
Center 05
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 1 1.000000 75.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 136 133.500000 5167.5000 1110.0000
P 75 129.000000 4967.2300 4967.2300
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
235 204.500000 7604.5000 75.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 447 468.000000 17814.2300 6152.2300
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 4 2.500000 117.1600 117.1600
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
843 730.000000 33218.1300 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 847 732.500000 33335.2900 117.1600
Center 07
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 37 40.750000 1659.7500 0.0000
P 119 155.000000 7211.0000 7211.0000
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 4 8.000000 600.0000 0.0000
T 0 0.000000 0.0000 0.0000
272 198.750000 7575.2500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 432 402.500000 17046.0000 7211.0000
Center 09
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 31 54.250000 2044.2500 0.0000
P 266 422.500000 19468.1300 19520.1300
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 93 131.000000 7323.7500 0.0000
T 128 184.750000 7969.5000 7548.0000
40 73.250000 4225.2500 0.0000
Other 54 102.500000 7395.0000 0.0000
---------------------------------------------------------
Total 612 968.250000 48425.8800 27068.1300
Center 10
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 20 21.750000 918.7500 0.0000
U 0 0.000000 0.0000 0.0000
B 50 63.250000 2613.0000 0.0000
P 311 355.500000 17289.2500 17023.9500
D 14 19.000000 1356.7500 0.0000
S 18 32.500000 2164.5000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
294 378.500000 19274.2500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 707 870.500000 43616.5000 17023.9500
Center 51
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 10 8.500000 569.2500 0.0000
P 6 6.000000 450.0000 450.0000
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
63 47.750000 2010.7500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 79 62.250000 3030.0000 450.0000
Center 52
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 20 28.500000 1460.7500 0.0000
P 86 143.500000 7119.2500 7010.2000
D 7 13.000000 721.5000 0.0000
S 10 11.250000 472.2500 33.7500
H 12 24.000000 1683.0000 0.0000
T 47 375.000000 2855.7800 2655.7800
124 185.000000 8802.7500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 306 780.250000 23115.2800 9699.7300
Center 53
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 217 227.500000 10722.0000 0.0000
P 121 129.250100 6141.7555 6141.7500
D 12 15.500000 847.2500 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
278 222.499900 10009.4945 0.0000
Other 1 1.000000 55.5000 0.0000
---------------------------------------------------------
Total 629 595.750000 27776.0000 6141.7500
Center 54
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 231 261.500000 11873.0000 0.0000
P 152 184.000000 8327.0000 8327.0000
D 6 11.000000 825.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 4 8.000000 444.0000 444.0000
267 324.000000 15983.7500 0.0000
Other 1 2.000000 150.0000 0.0000
---------------------------------------------------------
Total 661 790.500000 37602.7500 8771.0000
Center 55
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 430 544.000000 25904.0000 0.0000
P 90 151.533333 6347.4600 24609.7100
D 0 0.000000 0.0000 0.0000
S 1 0.836800 62.7600 0.0000
H 12 24.000000 1800.0000 0.0000
T 0 0.000000 0.0000 0.0000
639 594.379867 29784.9900 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 1172 1314.750000 63899.2100 24609.7100
Center 57
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 99 174.750000 6919.2500 0.0000
P 279 420.750000 19016.7500 18968.6500
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
473 622.500000 26951.2500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 851 1218.000000 52887.2500 18968.6500