CMS/EIP Fiscal Report Center: 07
Services beginning 10/01/2016 ending 12/31/2016 Date of Report:02/04/2017 Page: 1
List order: No List
Payclass Filters:MED
Eligibility Filter:Program Patients
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 1147 3729.500000 137926.7500 36.9826
Subtotal (Total Children Is Unduplicated) 1147 3729.500000 137926.7500 36.9826
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 12 25.000000 1875.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 15 29.500000 1637.2500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 6 10.000000 750.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 121 217.500000 12071.2500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 134 303.500000 22762.5000 75.0000
SCREEN-T1023-SCREENING 27 27.000000 1350.0000 50.0000
Subtotal (Total Children Is Unduplicated) 213 612.500000 40446.0000 66.0343
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 16 71.500000 3575.0000 50.0000
Subtotal (Total Children Is Unduplicated) 16 71.500000 3575.0000 50.0000
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Total 4413.500000 181947.7500 41.2253
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Number of Children (Unduplicated) With at Least One Service 1147
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Center 07
Flag Claims Units Chgs Paid
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R 6 4.750000 175.7500 0.0000
U 0 0.000000 0.0000 0.0000
B 228 154.500000 5868.2500 0.0000
P 5447 4189.250000 172834.7500 172797.7500
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 0 0.000000 0.0000 0.0000
38 65.000000 3069.0000 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 5719 4413.500000 181947.7500 172797.7500