CMS/EIP Fiscal Report Statewide
Services beginning 07/01/2021 ending 09/30/2021 Date of Report:10/13/2021 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 793 1039.000000 38341.2500 36.9021
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 57 45.250000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 1316 5884.000000 217523.0000 36.9686
Subtotal (Total Children Is Unduplicated) 1340 6968.250000 255864.2500 36.7186
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Screening, Eval, and Assessment,Class #02
EVAL-96111-DEVELOPMENTAL EVALUATION 1 2.000000 100.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 4 8.500000 618.0000 72.7059
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 21 37.000000 2775.0000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 4 6.500000 487.5000 75.0000
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 9 16.500000 1237.5000 75.0000
IPDEF-T1024TLTSGT-F/U PHYC AND DEV EVAL BY EI PROF 3 5.000000 375.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 11 20.500000 1137.7500 55.5000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 29 55.000000 3052.5000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 120 208.000000 15430.0000 74.1827
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 609 1002.999997 75103.3997 74.8788
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 54 85.000000 6375.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 240 384.499999 28787.5000 74.8700
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 44 74.000000 5550.0000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 176 290.000000 21750.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 148 257.000000 13999.5000 54.4728
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 717 1171.500000 64583.5000 55.1289
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 67 121.000000 9075.0000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 169 288.500000 21637.5000 75.0000
MED-99201-OUTPATIENT VISIT, NEW, 10 MINS 3 3.000000 163.7000 54.5667
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 15 15.000000 2354.1900 156.9460
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 1 1.000000 23.4200 23.4200
SCREEN-T1023-SCREENING 1 2.000000 100.0000 50.0000
Subtotal (Total Children Is Unduplicated) 1257 4054.499996 274715.9597 67.7558
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 1 0.500000 25.0000 50.0000
DSTT-DSTT-DIRECT SERVICE COORDINATOR TRAVEL 12 15.250000 0.0000 0.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 1 7.000000 350.0000 50.0000
INTR-T1013-INTERPRETER 33 63.500000 3195.0000 50.3150
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 28 50.000000 500.0000 10.0000
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 1 5.000000 357.2000 71.4400
TRAV-TRAVS-Travel by mile 40 1117.000000 495.6600 0.4437
Subtotal (Total Children Is Unduplicated) 102 1258.250000 4922.8600 3.9125
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Total 12280.999996 535503.0697 43.6042
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Number of Children (Unduplicated) With at Least One Service 1500
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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 46 124.750000 3494.7800 3494.7800
D 3 16.000000 106.0000 0.0000
S 83 111.500000 7584.0000 0.0000
H 7 9.500000 683.2500 0.0000
T 14 90.000000 956.7600 956.7600
62 85.000000 5839.7500 0.0000
Other 55 79.250000 4942.7500 0.0000
---------------------------------------------------------
Total 270 516.000000 23607.2900 4451.5400
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 19 355.500000 1266.6600 1266.6600
0 0.000000 0.0000 0.0000
Other 242 171.250000 6857.0000 0.0000
---------------------------------------------------------
Total 261 526.750000 8123.6600 1266.6600
Center 03
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 164 200.750000 10056.5000 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
204 262.000000 15289.7500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 368 462.750000 25346.2500 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 91 148.750000 6655.2500 0.0000
P 55 82.750000 3827.0000 3827.3300
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
337 439.250000 21876.5600 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 483 670.750000 32358.8100 3827.3300
Center 05
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 200 195.000000 7215.0000 3968.2500
P 65 323.000000 4195.2100 4195.2100
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
212 172.000000 6056.7200 192.2200
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 477 690.000000 17466.9300 8355.6800
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 22 28.000000 1164.0000 1164.0000
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
1212 1252.500000 59905.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 1234 1280.500000 61069.0000 1164.0000
Center 07
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 5 4.500000 166.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 36 57.000000 2520.0000 0.0000
P 166 193.250000 8750.2500 8720.2500
D 1 2.000000 150.0000 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
314 225.000000 8405.7500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 526 489.750000 20592.5000 8720.2500
Center 09
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 29 47.500000 2151.0000 0.0000
P 721 1040.500000 47309.7500 47657.0000
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 174 249.000000 14036.5000 0.0000
T 4 5.000000 187.2500 0.0000
220 288.500000 13688.5000 0.0000
Other 85 161.000000 11256.0000 0.0000
---------------------------------------------------------
Total 1233 1791.500000 88629.0000 47657.0000
Center 10
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 355 472.250000 22005.7500 0.0000
P 5 11.000000 370.0000 145.0000
D 6 11.250000 690.0000 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
303 421.000000 20997.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 669 915.500000 44062.7500 145.0000
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 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
38 42.500000 2031.7500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 39 43.500000 2041.7500 10.0000
Center 52
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 22 36.500000 1991.5000 0.0000
P 120 188.750000 8803.1200 8654.2600
D 12 24.000000 1410.0000 0.0000
S 5 7.250000 420.2500 0.0000
H 23 45.000000 3141.0000 0.0000
T 55 425.000000 3460.0600 2915.0600
154 183.000000 7417.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 391 909.500000 26642.9300 11569.3200
Center 53
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 159 180.000000 8308.0000 0.0000
P 120 139.500000 7095.0000 7095.0000
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
348 317.250000 14440.5000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 627 636.750000 29843.5000 7095.0000
Center 54
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 219 257.500000 11520.5000 0.0000
P 147 190.500000 8752.5000 8752.5000
D 1 2.000000 150.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 6 12.000000 861.0000 861.0000
246 280.500000 13604.7500 0.0000
Other 1 2.000000 74.0000 0.0000
---------------------------------------------------------
Total 620 744.500000 34962.7500 9613.5000
Center 55
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 543 685.000000 32210.0000 0.0000
P 25 41.375956 2505.5100 2505.5100
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 19 38.000000 2800.0000 0.0000
T 0 0.000000 0.0000 0.0000
672 638.124040 31414.1897 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 1259 1402.499996 68929.6997 2505.5100
Center 57
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 376 642.500000 27732.5000 0.0000
P 32 47.250000 2199.7500 2199.7500
D 4 4.500000 288.7500 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 1 3.750000 9.2500 129.5000
316 502.750000 21596.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 729 1200.750000 51826.2500 2329.2500