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: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 3 5.250000 195.3000 37.2000
Subtotal (Total Children Is Unduplicated) 3 5.250000 195.3000 37.2000
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Screening, Eval, and Assessment,Class #02
EVAL-96111GT-DEVELOPMENTAL EVALUATION 2 4.000000 200.0000 50.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 5 9.500000 712.5000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 4 7.000000 525.0000 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 2 2.500000 187.5000 75.0000
IPDEF-T1024TLTSGT-F/U PHYC AND DEV EVAL BY EI PROF 2 4.000000 300.0000 75.0000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 7 11.500000 638.2500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 85 166.500000 11978.6400 71.9438
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 86 135.500000 10162.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 35 64.000000 4800.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 52 82.500000 6187.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 38 77.500000 5482.9000 70.7471
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 30 48.500000 3637.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 66 115.000000 6382.5000 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 105 170.000000 9435.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 26 41.500000 3062.5000 73.7952
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 27 48.500000 3637.5000 75.0000
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 4 4.000000 1216.0000 304.0000
Subtotal (Total Children Is Unduplicated) 345 995.500000 68808.2900 69.1193
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 1 1.000000 50.0000 50.0000
Subtotal (Total Children Is Unduplicated) 1 1.000000 50.0000 50.0000
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Total 1001.750000 69053.5900 68.9330
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Number of Children (Unduplicated) With at Least One Service 347
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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 6 10.000000 681.7500 681.7500
D 1 1.500000 83.2500 0.0000
S 0 0.000000 0.0000 0.0000
H 17 22.500000 1570.5000 0.0000
T 0 0.000000 0.0000 0.0000
6 9.500000 683.2500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 30 43.500000 3018.7500 681.7500
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 4 6.500000 487.5000 487.5000
0 0.000000 0.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 4 6.500000 487.5000 487.5000
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 25.500000 1712.0000 1712.0000
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 5 8.500000 549.2400 549.2400
T 0 0.000000 0.0000 0.0000
0 0.000000 0.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 19 34.000000 2261.2400 2261.2400
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
22 25.500000 2809.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 22 25.500000 2809.0000 0.0000
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
80 118.000000 7962.7500 0.0000
Other 2 2.000000 130.5000 0.0000
---------------------------------------------------------
Total 82 120.000000 8093.2500 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 9 18.000000 1300.0000 1300.0000
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 1 2.000000 150.0000 0.0000
T 0 0.000000 0.0000 0.0000
11 21.250000 1470.9000 0.0000
Other 1 2.000000 150.0000 0.0000
---------------------------------------------------------
Total 22 43.250000 3070.9000 1300.0000
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 14 25.500000 1883.2500 1883.2500
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 3 5.500000 412.5000 412.5000
35 62.000000 3860.2500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 52 93.000000 6156.0000 2295.7500
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
92 166.000000 11416.5000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 92 166.000000 11416.5000 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 8 15.000000 873.9600 820.4200
D 9 18.000000 1350.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 10 20.000000 1500.0000 0.0000
T 19 37.500000 2116.8400 2022.8400
22 43.500000 2765.2500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 68 134.000000 8606.0500 2843.2600
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 5 7.000000 388.5000 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 2 3.500000 194.2500 194.2500
21 30.500000 2143.6500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 28 41.000000 2726.4000 194.2500
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 2 2.500000 187.5000 0.0000
T 12 19.000000 1191.0000 1191.0000
30 53.500000 3926.2500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 44 75.000000 5304.7500 1191.0000
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 0 0.000000 0.0000 0.0000
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 19 38.000000 2750.0000 0.0000
T 0 0.000000 0.0000 0.0000
17 34.000000 2550.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 36 72.000000 5300.0000 0.0000
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 0 0.000000 0.0000 0.0000
96 148.000000 9803.2500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 96 148.000000 9803.2500 0.0000