CMS/EIP Fiscal Report Statewide
Services beginning 04/01/2023 ending 06/30/2023 Date of Report:07/25/2023 Page: 1
List order: No List
Payclass Filters:TPIN
Eligibility Filter:Not Part C
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 1 1.250000 46.5000 37.2000
Subtotal (Total Children Is Unduplicated) 1 1.250000 46.5000 37.2000
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 9 17.500000 1275.0000 72.8571
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 5 9.000000 675.0000 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 4 6.500000 487.5000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 2 4.000000 300.0000 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 3 5.000000 375.0000 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 4 6.500000 360.7500 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 109 198.092801 14347.7600 72.4295
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 101 174.000000 13043.4900 74.9626
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 31 55.000000 4125.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 69 112.500000 8437.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 38 68.757999 4985.1000 72.5021
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 33 55.000000 4125.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 71 123.000000 6798.7500 55.2744
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 154 261.000000 14430.0000 55.2874
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 29 47.000000 3525.0000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 23 43.500000 3262.5000 75.0000
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 7 7.000000 2128.0000 304.0000
Subtotal (Total Children Is Unduplicated) 418 1211.850800 83922.6000 69.2516
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Total 1213.100800 83969.1000 69.2186
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Number of Children (Unduplicated) With at Least One Service 419
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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 14 24.000000 1347.7500 1347.7500
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 16 23.500000 1614.7500 1614.7500
0 0.000000 0.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 30 47.500000 2962.5000 2962.5000
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 1 1.500000 112.5000 112.5000
1 2.000000 150.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 2 3.500000 262.5000 112.5000
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 14 24.500000 1671.7500 1671.7500
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 4 7.000000 427.5000 427.5000
T 0 0.000000 0.0000 0.0000
31 51.500000 3521.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 49 83.000000 5620.2500 2099.2500
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
21 24.500000 3440.5000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 21 24.500000 3440.5000 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 2 3.000000 225.0000 225.0000
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 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 2 3.000000 225.0000 225.0000
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
70 105.500000 7054.5000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 70 105.500000 7054.5000 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 18 36.000000 2700.0000 2700.0000
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 5 10.000000 750.0000 0.0000
T 0 0.000000 0.0000 0.0000
5 10.000000 750.0000 0.0000
Other 1 2.000000 150.0000 0.0000
---------------------------------------------------------
Total 29 58.000000 4350.0000 2700.0000
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 8 14.500000 1087.5000 1087.5000
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 2 4.000000 261.0000 261.0000
37 59.500000 3780.0000 0.0000
Other 10 19.500000 1384.5000 0.0000
---------------------------------------------------------
Total 57 97.500000 6513.0000 1348.5000
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 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
129 232.000000 15645.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 129 232.000000 15645.0000 0.0000
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 13 26.000000 1531.0000 1081.8000
D 6 12.000000 666.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 21 42.000000 3111.0000 0.0000
T 18 36.000000 2049.8000 1884.0000
13 26.000000 1833.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 71 142.000000 9190.8000 2965.8000
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 2 2.000000 111.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 1 2.000000 111.0000 111.0000
27 39.250000 2604.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 30 43.250000 2826.0000 111.0000
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 1 1.000000 75.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 2 3.000000 225.0000 0.0000
T 12 20.500000 1206.0000 1206.0000
48 88.000000 6200.2500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 63 112.500000 7706.2500 1206.0000
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 10 20.000000 1500.0000 1500.0000
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 25 50.000000 3750.0000 0.0000
T 0 0.000000 0.0000 0.0000
25 33.850800 2538.8100 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 60 103.850800 7788.8100 1500.0000
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 2 3.000000 186.0000 400.0000
D 8 13.500000 905.2500 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
84 140.500000 9292.7400 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 94 157.000000 10383.9900 400.0000