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:TPIN
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 1 0.500000 18.6000 37.2000
TCM-T1017TL-TARGETED CASE MANAGEMENT 4 11.750000 437.1000 37.2000
Subtotal (Total Children Is Unduplicated) 4 12.250000 455.7000 37.2000
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 4 6.600000 495.0000 75.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 2 3.500000 262.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 1 3.000000 225.0000 75.0000
IPDEF-T1024TLTSGT-F/U PHYC AND DEV EVAL BY EI PROF 2 4.000000 300.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 1 2.000000 111.0000 55.5000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 1 1.500000 83.2500 55.5000
IPDEI-IPDEI_NM-INITIAL PSYCH & DEV EVAL BY NON-MED PR 1 2.000000 111.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 104 193.759734 14367.1800 74.1495
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 72 119.663200 8974.7400 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 39 67.572533 5067.9400 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 40 66.500000 5025.0000 75.5639
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 40 64.000000 4670.6900 72.9795
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 19 34.500000 2587.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 91 155.500000 8630.2500 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 70 115.500000 6410.2500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 39 69.500000 5212.5000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 22 35.500000 2662.5000 75.0000
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 1 1.000000 304.0000 304.0000
Subtotal (Total Children Is Unduplicated) 330 945.595467 65500.3000 69.2688
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Total 957.845467 65956.0000 68.8587
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Number of Children (Unduplicated) With at Least One Service 332
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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 21.500000 1300.5000 1300.5000
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 55 79.500000 5455.5000 0.0000
T 6 8.500000 549.7500 549.7500
8 11.500000 862.5000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 83 121.000000 8168.2500 1850.2500
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 2 2.500000 187.5000 187.5000
0 0.000000 0.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 2 2.500000 187.5000 187.5000
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 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
17 27.000000 1807.9400 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 19 30.000000 2032.9400 225.0000
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
6 8.500000 866.5000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 6 8.500000 866.5000 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 1 1.500000 83.2500 83.2500
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 0 0.000000 0.0000 0.0000
0 0.000000 0.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 1 1.500000 83.2500 83.2500
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 2 4.000000 222.0000 222.0000
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
66 110.000000 7567.5000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 68 114.000000 7789.5000 222.0000
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 3 6.000000 450.0000 450.0000
D 5 10.000000 750.0000 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 25.500000 1704.6000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 23 41.500000 2904.6000 450.0000
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 2 3.000000 225.0000 225.0000
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 24 32.500000 2193.7500 2193.7500
T 0 0.000000 0.0000 0.0000
10 15.000000 1037.2500 0.0000
Other 5 8.000000 502.5000 0.0000
---------------------------------------------------------
Total 41 58.500000 3958.5000 2418.7500
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
139 259.500000 17756.2500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 139 259.500000 17756.2500 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 5 9.000000 640.1600 562.1500
D 3 6.000000 450.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 8 15.500000 1162.5000 0.0000
T 21 42.000000 2825.0400 2632.6400
20 37.500000 2422.5000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 57 110.000000 7500.2000 3194.7900
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 1.500000 83.2500 0.0000
S 0 0.000000 0.0000 0.0000
H 3 4.500000 337.5000 0.0000
T 0 0.000000 0.0000 0.0000
10 17.000000 1234.5000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 14 23.000000 1655.2500 0.0000
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 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 1 1.500000 112.5000 0.0000
T 8 15.000000 988.5000 988.5000
21 35.750000 2396.8500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 30 52.250000 3497.8500 988.5000
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 3 6.000000 450.0000 450.0000
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 15 30.000000 2250.0000 0.0000
T 0 0.000000 0.0000 0.0000
19 31.095467 2332.1600 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 37 67.095467 5032.1600 450.0000
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
48 68.500000 4523.2500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 48 68.500000 4523.2500 0.0000