CMS/EIP Fiscal Report Statewide
Services beginning 07/01/2023 ending 09/30/2023 Date of Report:10/11/2023 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 790 962.750000 35814.3000 37.2000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 150 171.250000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 653 3147.750000 116938.2000 37.1498
Subtotal (Total Children Is Unduplicated) 1066 4281.750000 152752.5000 35.6753
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Screening, Eval, and Assessment,Class #02
EVAL-96111GT-DEVELOPMENTAL EVALUATION 2 4.000000 200.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 3 4.500000 337.5000 75.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 1 2.000000 150.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 2 4.000000 300.0000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 3 5.000000 375.0000 75.0000
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 1 2.000000 150.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 2 5.500000 412.5000 75.0000
IPDEF-T1024TLTSGT-F/U PHYC 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 4 7.000000 388.5000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 51 85.000000 6375.0000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 61 109.500000 8212.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 34 61.000000 4687.5000 76.8443
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 40 69.000000 5175.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 13 23.000000 1725.0000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 28 46.500000 3487.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 115 203.000000 11238.7500 55.3633
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 107 184.000000 10212.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 25 42.000000 3150.0000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 20 35.000000 2625.0000 75.0000
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 1 1.000000 76.1500 76.1500
Subtotal (Total Children Is Unduplicated) 335 906.000000 60038.4000 66.2676
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EI Services,Class #03
COIFF-COIFFGT-IFSP CONSULT, PROF, TELEMEDICINE 1 0.500000 25.0000 50.0000
CONIF-CONIFGT-CONSULT, ITDS, TELEMEDICINE 1 2.000000 100.0000 50.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 1 1.000000 50.0000 50.0000
CONSP-CONSP-CONSULT, SLP, PHONE 1 2.000000 50.0000 25.0000
DSTT-DSTT-DIRECT SERVICE COORDINATOR TRAVEL 47 91.000000 0.0000 0.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 1 9.000000 450.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 1 3.000000 150.0000 50.0000
EPIC-99601-Early Steps Professional Development Fee 34 40.000000 600.0000 15.0000
INTR-T1013-INTERPRETER 33 76.000000 3845.0000 50.5921
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 70 96.000000 1152.0000 12.0000
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 1 0.250000 21.7900 87.1600
TRAV-TRAVS-Travel by mile 138 4764.000000 2118.9200 0.4448
Subtotal (Total Children Is Unduplicated) 232 5084.750000 8562.7100 1.6840
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Total 10272.500000 221353.6100 21.5482
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Number of Children (Unduplicated) With at Least One Service 1185
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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 25 143.500000 1190.4600 1190.4600
D 0 0.000000 0.0000 0.0000
S 1 1.500000 75.0000 75.0000
H 0 0.000000 0.0000 0.0000
T 9 26.750000 544.6200 544.6200
5 8.000000 561.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 40 179.750000 2371.0800 1810.0800
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 42 1106.500000 2724.9100 2724.9100
15 277.500000 902.8700 0.0000
Other 508 1519.750000 11834.2500 0.0000
---------------------------------------------------------
Total 565 2903.750000 15462.0300 2724.9100
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 39 146.500000 3263.3200 3263.3200
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 15 26.500000 1741.0000 1741.0000
T 0 0.000000 0.0000 0.0000
80 115.500000 4359.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 134 288.500000 9363.3200 5004.3200
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
200 297.250000 13357.6000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 200 297.250000 13357.6000 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 146 1537.000000 6439.1300 6439.1300
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
396 343.000000 8427.8000 299.6000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 542 1880.000000 14866.9300 6738.7300
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
270 227.000000 8661.3000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 270 227.000000 8661.3000 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 58 114.000000 2258.8000 2258.8000
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
394 313.750000 11804.1000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 452 427.750000 14062.9000 2258.8000
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 348 436.750000 18811.4000 18811.4000
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 21.250000 1186.2000 1186.2000
33 45.750000 2091.2000 0.0000
Other 19 35.500000 2448.0000 0.0000
---------------------------------------------------------
Total 418 539.250000 24536.8000 19997.6000
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
263 312.250000 13687.3500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 263 312.250000 13687.3500 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 6 5.250000 168.7900 168.7900
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
1 1.000000 55.5000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 7 6.250000 224.2900 168.7900
Center 52
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 1 1.250000 46.5000 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 27 369.000000 164.2000 164.2000
148 194.500000 5631.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 176 564.750000 5841.7000 164.2000
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 7 9.500000 588.7500 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 5 5.000000 277.5000 222.0000
473 332.500000 13173.6000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 485 347.000000 14039.8500 222.0000
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 6 10.000000 484.2000 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 19 88.000000 1121.3600 1121.3600
454 512.500000 16398.8000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 479 610.500000 18004.3600 1121.3600
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 8 14.750000 882.9000 882.9000
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
678 652.500000 25751.3000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 686 667.250000 26634.2000 882.9000
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
367 1021.250000 40239.9000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 367 1021.250000 40239.9000 0.0000