CMS/EIP Fiscal Report Center: 07
Services beginning 10/01/2017 ending 12/31/2017 Date of Report:02/03/2018 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 1173 3499.000000 129463.0000 37.0000
Subtotal (Total Children Is Unduplicated) 1173 3499.000000 129463.0000 37.0000
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 7 14.500000 1087.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 7 13.000000 721.5000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 23 44.000000 3300.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 119 221.000000 12265.5000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 144 317.500000 23812.5000 75.0000
SCREEN-T1023-SCREENING 5 5.000000 250.0000 50.0000
Subtotal (Total Children Is Unduplicated) 197 615.000000 41437.0000 67.3772
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 6 14.750000 737.5000 50.0000
Subtotal (Total Children Is Unduplicated) 6 14.750000 737.5000 50.0000
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Total 4128.750000 171637.5000 41.5713
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Number of Children (Unduplicated) With at Least One Service 1174
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Center 07
Flag Claims Units Chgs Paid
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R 19 12.500000 538.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 11 8.000000 524.0000 0.0000
P 5072 4090.000000 169860.7500 169860.7500
D 0 0.000000 0.0000 0.0000
S 6 9.750000 373.7500 0.0000
H 0 0.000000 0.0000 0.0000
T 1 0.500000 18.5000 0.0000
16 7.500000 303.5000 0.0000
Other 2 0.500000 18.5000 0.0000
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Total 5127 4128.750000 171637.5000 169860.7500