CMS/EIP Fiscal Report Statewide
Services beginning 10/01/2023 ending 12/31/2023 Date of Report:01/14/2024 Page: 1
List order: No List
Payclass Filters:OTHER
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 46 68.500000 2548.2000 37.2000
Subtotal (Total Children Is Unduplicated) 46 68.500000 2548.2000 37.2000
-----------------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
EXIT-EXIT-COS Exit 1 1.000000 50.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 1 1.500000 112.5000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 1 1.000000 75.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 1 1.500000 83.2500 55.5000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 1 1.000000 55.5000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 9 15.000000 1125.0000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 19 27.000000 2025.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 1 1.000000 75.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 11 13.000000 975.0000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 5 8.500000 637.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 11 16.000000 888.0000 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 38 51.000000 2830.5000 55.5000
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 3 3.000000 228.4500 76.1500
Subtotal (Total Children Is Unduplicated) 60 140.500000 9160.7000 65.2007
-----------------------------------------------------------------------------------------------------------------------
Total 209.000000 11708.9000 56.0234
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 65
-----------------------------------------------------------------------------------------------------------------------
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
15 20.500000 1194.2000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 15 20.500000 1194.2000 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 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
0 0.000000 0.0000 0.0000
Other 15 10.750000 399.9000 0.0000
---------------------------------------------------------
Total 15 10.750000 399.9000 0.0000
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 6 10.500000 748.5000 748.5000
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 123 164.500000 9264.0000 0.0000
T 0 0.000000 0.0000 0.0000
1 1.000000 37.2000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 130 176.000000 10049.7000 748.5000
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
1 1.750000 65.1000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 1 1.750000 65.1000 0.0000