CMS/EIP Fiscal Report Statewide
Services beginning 01/01/2021 ending 03/31/2021 Date of Report:05/04/2021 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 790 922.250000 34123.2500 37.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 43 31.750000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 611 2748.500000 101694.5000 37.0000
Subtotal (Total Children Is Unduplicated) 1107 3702.500000 135817.7500 36.6827
-----------------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
EVAL-96111-DEVELOPMENTAL EVALUATION 5 9.000000 450.0000 50.0000
EVAL-96111GT-DEVELOPMENTAL EVALUATION 9 18.500000 925.0000 50.0000
EXIT-EXIT-EXIT ASSESSMENT 1 1.000000 50.0000 50.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 3 5.500000 412.5000 75.0000
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 1 2.000000 150.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 2 3.000000 166.5000 55.5000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 3 5.500000 305.2500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 9 10.833333 793.0000 73.2000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 94 155.603467 11579.3200 74.4156
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 7 11.000000 825.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 47 73.903200 5542.7400 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 2 3.500000 262.5000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 57 91.000000 6825.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 32 52.000000 2886.0000 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 163 256.000000 14208.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 10 17.500000 1312.5000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 49 75.000000 5625.0000 75.0000
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 4 4.000000 235.6400 58.9100
SCREEN-T1023-SCREENING 2 2.000000 100.0000 50.0000
Subtotal (Total Children Is Unduplicated) 302 796.840000 52653.9500 66.0784
-----------------------------------------------------------------------------------------------------------------------
EI Services,Class #03
CONSF-CONSFGT-CONSULT,SLP,FACE TO FACE 1 1.000000 50.0000 50.0000
DSTT-DSTT-DIRECT SERVICE COORDINATOR TRAVEL 10 10.500000 0.0000 0.0000
INTR-T1013-INTERPRETER 30 50.750000 2537.5000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 32 45.000000 450.0000 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 1.000000 71.4400 71.4400
TRAV-TRAVS-Travel by mile 29 888.000000 395.1100 0.4449
Subtotal (Total Children Is Unduplicated) 94 998.250000 3646.9300 3.6533
-----------------------------------------------------------------------------------------------------------------------
Total 5497.590000 192118.6300 34.9460
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 1169
-----------------------------------------------------------------------------------------------------------------------
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 36 51.250000 2791.7500 2791.7500
D 2 2.500000 77.0600 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 1 1.500000 112.5000 112.5000
390 320.750000 14548.7500 0.0000
Other 2 0.750000 27.7500 0.0000
---------------------------------------------------------
Total 431 376.750000 17557.8100 2904.2500
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 18 659.000000 701.5800 701.5800
0 0.000000 0.0000 0.0000
Other 279 193.500000 8550.7500 0.0000
---------------------------------------------------------
Total 297 852.500000 9252.3300 701.5800
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
194 206.750000 9556.7500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 194 206.750000 9556.7500 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 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
181 210.000000 9369.8900 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 181 210.000000 9369.8900 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 94 187.000000 6477.0500 6477.0500
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
302 251.250000 9316.2500 112.5000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 396 438.250000 15793.3000 6589.5500
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 4.000000 40.0000 40.0000
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
437 310.500000 11625.7500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 441 314.500000 11665.7500 40.0000
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 17 19.000000 372.0000 372.0000
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
417 286.000000 10723.5000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 435 307.000000 11245.5000 372.0000
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 401 579.750000 25723.2500 25723.2500
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
11 21.000000 1536.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 412 600.750000 27259.2500 25723.2500
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 2 2.000000 60.0000 60.0000
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
373 402.000000 16038.2500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 375 404.000000 16098.2500 60.0000
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 7 8.000000 527.8800 527.8800
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
92 83.250000 3449.6900 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 99 91.250000 3977.5700 527.8800
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 1 1.000000 37.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 12 159.000000 70.7300 70.7300
79 94.500000 3394.7500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 92 254.500000 3502.4800 70.7300
Center 53
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 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 1 1.500000 83.2500 83.2500
265 193.000000 8093.7500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 266 194.500000 8177.0000 83.2500
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 3 4.500000 249.7500 249.7500
184 157.250000 6434.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 187 161.750000 6683.7500 249.7500
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 9 17.800000 990.0000 990.0000
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
622 404.040000 15976.7500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 631 421.840000 16966.7500 990.0000
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 0 0.000000 0.0000 0.0000
453 663.250000 25012.2500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 453 663.250000 25012.2500 0.0000