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
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 647 801.750000 29582.0000 36.8968
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 31 25.000000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 466 2185.500000 80724.7500 36.9365
Subtotal (Total Children Is Unduplicated) 899 3012.250000 110306.7500 36.6194
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Screening, Eval, and Assessment,Class #02
EVAL-96111-DEVELOPMENTAL EVALUATION 2 3.500000 175.0000 50.0000
EVAL-96111GT-DEVELOPMENTAL EVALUATION 1 2.000000 100.0000 50.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 3 4.500000 325.6600 72.3689
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 1 1.000000 75.0000 75.0000
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 4 7.000000 525.0000 75.0000
IPDEF-T1024TLTSGT-F/U PHYC AND DEV EVAL BY EI PROF 1 2.000000 150.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 1 1.000000 55.5000 55.5000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 6 9.500000 527.2500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 14 23.000000 1675.0000 72.8261
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 81 124.006934 9300.5200 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 3 4.500000 337.5000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 44 69.533333 5215.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 6 7.500000 562.5000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 38 60.500000 4537.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 30 52.500000 2913.7500 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 106 165.999900 9212.9945 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 4 8.000000 600.0000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 31 49.000000 3675.0000 75.0000
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 8 8.000000 471.2800 58.9100
SCREEN-T1023-SCREENING 2 2.000000 100.0000 50.0000
Subtotal (Total Children Is Unduplicated) 231 605.040167 40534.4545 66.9947
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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 1 6.000000 300.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 1 1.000000 50.0000 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
TRAV-TRAVS-Travel by mile 31 711.000000 316.3300 0.4449
Subtotal (Total Children Is Unduplicated) 76 800.750000 2378.8300 2.9708
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Total 4418.040167 153220.0345 34.6805
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Number of Children (Unduplicated) With at Least One Service 939
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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 14 20.750000 1245.7500 1245.7500
D 3 2.750000 163.1600 0.0000
S 2 1.000000 37.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 11 33.250000 808.2000 808.2000
299 236.750000 10367.7500 0.0000
Other 3 0.750000 27.7500 0.0000
---------------------------------------------------------
Total 332 295.250000 12649.6100 2053.9500
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 10 294.000000 478.1600 478.1600
0 0.000000 0.0000 0.0000
Other 156 99.500000 4197.5000 0.0000
---------------------------------------------------------
Total 166 393.500000 4675.6600 478.1600
Center 03
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 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
239 264.250000 12271.7500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 239 264.250000 12271.7500 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 5 16.000000 400.0000 400.0000
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
136 136.750000 6105.7800 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 141 152.750000 6505.7800 400.0000
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 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 310 333.500000 12571.7300 5042.2300
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 1 1.000000 10.0000 10.0000
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
394 268.000000 10195.2500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 395 269.000000 10205.2500 10.0000
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 11 13.000000 301.0000 301.0000
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
265 186.750000 6770.2500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 278 203.750000 7371.2500 301.0000
Center 09
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 0 0.000000 0.0000 0.0000
P 163 241.500000 10514.7500 10514.7500
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 119 167.750000 6934.5000 6934.5000
0 0.000000 0.0000 0.0000
Other 2 4.000000 300.0000 0.0000
---------------------------------------------------------
Total 284 413.250000 17749.2500 17449.2500
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
227 245.000000 9963.7500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 227 245.000000 9963.7500 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 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
42 29.750000 1185.5000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 48 35.750000 1635.5000 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 0 0.000000 0.0000 0.0000
P 1 2.000000 111.0000 59.4800
D 0 0.000000 0.0000 0.0000
S 2 2.500000 92.5000 0.0000
H 0 0.000000 0.0000 0.0000
T 28 339.000000 449.0300 429.0300
90 122.000000 4467.7500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 121 465.500000 5120.2800 488.5100
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 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
252 178.499900 7129.9945 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 252 178.499900 7129.9945 0.0000
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 0 0.000000 0.0000 0.0000
T 4 8.000000 444.0000 444.0000
212 224.000000 9348.5000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 216 232.000000 9792.5000 444.0000
Center 55
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 0 0.000000 0.0000 0.0000
P 12 48.533333 1320.4600 1320.4600
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
520 366.506934 14158.0200 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 532 415.040267 15478.4800 1320.4600
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 0 0.000000 0.0000 0.0000
397 521.000000 20099.2500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 397 521.000000 20099.2500 0.0000