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
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 793 1039.000000 38341.2500 36.9021
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 57 45.250000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 529 2357.500000 87024.0000 36.9137
Subtotal (Total Children Is Unduplicated) 1014 3441.750000 125365.2500 36.4249
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 3 5.500000 412.5000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 1 2.000000 150.0000 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 4.000000 222.0000 55.5000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 4 7.500000 416.2500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 17 29.500000 2212.5000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 104 163.347196 12179.6897 74.5632
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 9 15.000000 1125.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 42 70.435866 5282.6900 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 10 15.000000 1125.0000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 35 55.500000 4162.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 42 75.000000 4162.5000 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 136 214.000000 11877.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 23 39.000000 2925.0000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 42 58.000000 4350.0000 75.0000
MED-99201-OUTPATIENT VISIT, NEW, 10 MINS 2 2.000000 60.7000 30.3500
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 7 7.000000 412.3700 58.9100
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 1 1.000000 23.4200 23.4200
Subtotal (Total Children Is Unduplicated) 313 765.783062 51249.1197 66.9238
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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 14.250000 0.0000 0.0000
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 1.440090 102.8800 71.4400
TRAV-TRAVS-Travel by mile 40 1117.000000 495.6600 0.4437
Subtotal (Total Children Is Unduplicated) 102 1246.690090 4318.5400 3.4640
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Total 5454.223152 180932.9097 33.1730
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Number of Children (Unduplicated) With at Least One Service 1127
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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 30 99.250000 2011.2800 2011.2800
D 3 16.000000 106.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 7 79.500000 315.5100 315.5100
50 68.000000 4662.2500 0.0000
Other 4 3.250000 120.2500 0.0000
---------------------------------------------------------
Total 94 266.000000 7215.2900 2326.7900
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 17 352.000000 1004.1600 1004.1600
0 0.000000 0.0000 0.0000
Other 173 109.250000 4029.2500 0.0000
---------------------------------------------------------
Total 190 461.250000 5033.4100 1004.1600
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
160 185.500000 9591.2500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 160 185.500000 9591.2500 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 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
284 376.000000 16263.2400 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 284 376.000000 16263.2400 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 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 277 495.000000 10251.9300 4387.4300
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 14 16.000000 381.0000 381.0000
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
528 442.000000 16980.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 542 458.000000 17361.0000 381.0000
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 2 2.000000 20.0000 20.0000
D 1 2.000000 150.0000 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
300 198.000000 6728.7500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 305 206.000000 7198.7500 20.0000
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 457 619.500000 27178.0000 27178.0000
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
171 201.500000 7729.0000 0.0000
Other 5 9.000000 616.5000 0.0000
---------------------------------------------------------
Total 633 830.000000 35523.5000 27178.0000
Center 10
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 0 0.000000 0.0000 0.0000
P 3 7.000000 70.0000 70.0000
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
251 320.500000 14229.2500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 254 327.500000 14299.2500 70.0000
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
24 27.500000 1128.5000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 25 28.500000 1138.5000 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 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 29 373.000000 165.9300 165.9300
138 154.250000 5540.7500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 167 527.250000 5706.6800 165.9300
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
296 228.750000 9002.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 296 228.750000 9002.0000 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 2 4.000000 300.0000 300.0000
181 171.250000 6807.5000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 183 175.250000 7107.5000 300.0000
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 16 24.375956 1234.0700 1234.0700
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
554 418.847196 16420.5397 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 570 443.223152 17654.6097 1234.0700
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 1 3.750000 9.2500 129.5000
267 442.250000 17576.7500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 268 446.000000 17586.0000 129.5000