CMS/EIP Fiscal Report Statewide
Services beginning 10/01/2021 ending 12/31/2021 Date of Report:02/04/2022 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 826 983.500000 36380.2500 36.9906
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 62 50.000000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 696 2793.500000 103285.5000 36.9735
Subtotal (Total Children Is Unduplicated) 1173 3827.000000 139665.7500 36.4948
-----------------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 1 2.000000 150.0000 75.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 6 10.500000 787.5000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 3 6.000000 450.0000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 3 4.000000 300.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 1.766267 132.4700 75.0000
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 2 3.500000 262.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 1 2.000000 150.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 6 11.000000 610.5000 55.5000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 13 21.000000 1165.5000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 30 48.000000 3512.5000 73.1771
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 87 144.300000 10750.4000 74.5003
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 8 12.500000 712.5000 57.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 36 56.800000 4260.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 10 17.000000 1275.0000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 47 75.000000 5625.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 76 127.000000 6868.1300 54.0798
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 139 225.500000 12515.2500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 14 21.830900 1637.3175 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 27 37.000000 2775.0000 75.0000
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 7 7.000000 490.1900 70.0271
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 1 1.000000 51.0500 51.0500
Subtotal (Total Children Is Unduplicated) 317 834.697167 54480.8075 65.2701
-----------------------------------------------------------------------------------------------------------------------
EI Services,Class #03
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 1 0.500000 25.0000 50.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 1 1.000000 50.0000 50.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 1 1.500000 75.0000 50.0000
DSTT-DSTT-DIRECT SERVICE COORDINATOR TRAVEL 17 26.000000 0.0000 0.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 2 13.000000 650.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 1 2.000000 100.0000 50.0000
INTR-T1013-INTERPRETER 25 73.750000 3687.5000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 80 170.000000 1700.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 1 1.000000 71.4400 71.4400
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 1 5.000000 357.2000 71.4400
TRAV-TRAVS-Travel by mile 54 1644.000000 731.4300 0.4449
Subtotal (Total Children Is Unduplicated) 162 1937.750000 7447.5700 3.8434
-----------------------------------------------------------------------------------------------------------------------
Total 6599.447167 201594.1275 30.5471
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 1284
-----------------------------------------------------------------------------------------------------------------------
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 86.750000 888.3400 888.3400
D 3 17.000000 94.1300 0.0000
S 1 0.250000 9.2500 0.0000
H 0 0.000000 0.0000 0.0000
T 9 14.500000 725.0000 725.0000
19 24.750000 1453.5000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 46 143.250000 3170.2200 1613.3400
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 22 723.250000 842.7100 842.7100
2 56.000000 24.9200 0.0000
Other 340 180.250000 6994.7500 0.0000
---------------------------------------------------------
Total 364 959.500000 7862.3800 842.7100
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 2 11.000000 550.0000 550.0000
T 0 0.000000 0.0000 0.0000
171 197.000000 9216.0000 0.0000
Other 1 1.500000 83.2500 0.0000
---------------------------------------------------------
Total 174 209.500000 9849.2500 550.0000
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
184 230.500000 10461.9400 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 184 230.500000 10461.9400 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 138 344.000000 8828.2700 8828.2700
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
377 348.750000 10776.8800 278.1300
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 515 692.750000 19605.1500 9106.4000
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 27 29.000000 230.0000 230.0000
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
536 475.500000 18222.5000 0.0000
Other 38 32.000000 1184.0000 0.0000
---------------------------------------------------------
Total 601 536.500000 19636.5000 230.0000
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 40 48.000000 1016.5000 1016.5000
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
465 357.080900 12835.3175 0.0000
Other 1 2.250000 83.2500 0.0000
---------------------------------------------------------
Total 506 407.330900 13935.0675 1016.5000
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 478 655.000000 28577.0000 28577.0000
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
0 0.000000 0.0000 0.0000
Other 2 4.000000 261.0000 0.0000
---------------------------------------------------------
Total 480 659.000000 28838.0000 28577.0000
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 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
309 386.000000 17668.2500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 309 386.000000 17668.2500 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 25 35.500000 825.3800 825.3800
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
8 9.000000 577.5000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 33 44.500000 1402.8800 825.3800
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 40 571.000000 254.0200 254.0200
130 157.000000 5540.7500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 170 728.000000 5794.7700 254.0200
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
294 227.250000 9278.2500 0.0000
Other 1 0.500000 18.5000 0.0000
---------------------------------------------------------
Total 295 227.750000 9296.7500 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 6 11.000000 766.5000 766.5000
324 305.000000 12337.2500 0.0000
Other 6 2.750000 101.7500 0.0000
---------------------------------------------------------
Total 336 318.750000 13205.5000 766.5000
Center 55
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 0 0.000000 0.0000 0.0000
P 9 17.600000 1125.0000 1125.0000
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
513 352.016267 13477.7200 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 522 369.616267 14602.7200 1125.0000
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 12 38.000000 968.2500 968.2500
385 648.500000 25296.5000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 397 686.500000 26264.7500 968.2500