CMS/EIP Fiscal Report Statewide
Services beginning 10/01/2022 ending 12/31/2022 Date of Report:01/23/2023 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 732 822.500000 30596.7500 37.1997
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 93 93.000000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 703 2838.750000 105526.5000 37.1736
Subtotal (Total Children Is Unduplicated) 1073 3754.250000 136123.2500 36.2584
-----------------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
EVAL-96111-DEVELOPMENTAL EVALUATION 3 10.000000 500.0000 50.0000
EVAL-96111GT-DEVELOPMENTAL EVALUATION 1 4.000000 200.0000 50.0000
EXIT-EXIT-EXIT ASSESSMENT 1 0.500000 25.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 1 1.500000 112.5000 75.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 9 15.500000 1162.5000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 6 10.000000 750.0000 75.0000
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 2 3.000000 225.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 4 7.500000 416.2500 55.5000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 7 12.500000 693.7500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 38 68.333333 5125.0000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 83 133.500000 10012.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 16 30.500000 2187.5000 71.7213
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 37 59.000000 4425.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 8 14.000000 1050.0000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 35 56.000000 4200.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 99 174.000000 9657.0000 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 159 257.000000 14263.5000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 19 27.600000 2070.0000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 21 32.500000 2437.5000 75.0000
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 5 5.000000 380.7500 76.1500
Subtotal (Total Children Is Unduplicated) 340 921.933333 59893.7500 64.9654
-----------------------------------------------------------------------------------------------------------------------
EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 1 0.250000 12.5000 50.0000
DSTT-DSTT-DIRECT SERVICE COORDINATOR TRAVEL 43 49.750000 0.0000 0.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 2 10.000000 500.0000 50.0000
INTR-T1013-INTERPRETER 30 68.750000 3437.5000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 91 156.000000 1560.0000 10.0000
TRAV-TRAVS-Travel by mile 99 3822.000000 1698.4400 0.4444
Subtotal (Total Children Is Unduplicated) 185 4106.750000 7208.4400 1.7553
-----------------------------------------------------------------------------------------------------------------------
Total 8782.933333 203225.4400 23.1387
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 1160
-----------------------------------------------------------------------------------------------------------------------
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 13 54.250000 639.8900 639.8900
D 2 29.000000 12.0500 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 19 24.500000 1032.5000 1032.5000
118 80.750000 3003.9000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 152 188.500000 4688.3400 1672.3900
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 44 1493.250000 2183.7900 2173.1100
3 118.000000 52.5100 0.0000
Other 358 694.000000 7976.8300 0.0000
---------------------------------------------------------
Total 405 2305.250000 10213.1300 2173.1100
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 23 42.000000 3052.5000 3052.5000
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
226 267.500000 11265.4500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 249 309.500000 14317.9500 3052.5000
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 3 8.000000 80.0000 80.0000
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
247 278.000000 12829.5000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 250 286.000000 12909.5000 80.0000
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 164 964.750000 10091.1900 10091.1900
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
452 398.500000 12059.9900 163.6400
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 616 1363.250000 22151.1800 10254.8300
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 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
334 292.500000 11443.6500 0.0000
Other 9 6.500000 241.8000 0.0000
---------------------------------------------------------
Total 343 299.000000 11685.4500 0.0000
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 21 26.000000 693.0000 693.0000
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
259 208.850000 7738.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 280 234.850000 8431.0000 693.0000
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 249 324.500000 14098.5000 14098.5000
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 113 141.250000 5713.0000 5713.0000
0 0.000000 0.0000 0.0000
Other 2 3.500000 262.5000 0.0000
---------------------------------------------------------
Total 364 469.250000 20074.0000 19811.5000
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 18.000000 540.0000 540.0000
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
315 538.500000 22953.6000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 317 556.500000 23493.6000 540.0000
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 15 15.000000 468.5000 468.5000
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
0 0.000000 0.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 15 15.000000 468.5000 468.5000
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 2 4.000000 261.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 27 460.000000 353.7600 333.7600
110 102.500000 3715.4500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 139 566.500000 4330.2100 333.7600
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 1 0.500000 18.5000 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 12 150.000000 124.0700 124.0700
370 294.000000 9446.9500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 383 444.500000 9589.5200 124.0700
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 3 4.250000 157.5000 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 14 74.000000 599.1300 599.1300
326 475.000000 11220.1800 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 343 553.250000 11976.8100 599.1300
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 32.000000 2194.0000 2194.0000
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
588 462.083333 18094.6500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 604 494.083333 20288.6500 2194.0000
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 2 8.000000 80.0000 80.0000
437 689.500000 28527.6000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 439 697.500000 28607.6000 80.0000