CMS/EIP Fiscal Report Center: 07
Services beginning 10/01/2018 ending 12/31/2018 Date of Report:02/06/2019 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 1115 2822.750000 104358.5000 36.9705
Subtotal (Total Children Is Unduplicated) 1115 2822.750000 104358.5000 36.9705
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 7 13.500000 1012.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 4 8.000000 600.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 7 13.500000 749.2500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 91 178.000000 13350.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 103 200.000000 11100.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 99 209.500000 15712.5000 75.0000
SCREEN-T1023-SCREENING 6 6.000000 300.0000 50.0000
Subtotal (Total Children Is Unduplicated) 193 628.500000 42824.2500 68.1372
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 3 13.000000 621.6400 47.8185
Subtotal (Total Children Is Unduplicated) 3 13.000000 621.6400 47.8185
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Total 3464.250000 147804.3900 42.6656
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Number of Children (Unduplicated) With at Least One Service 1119
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Center 07
Flag Claims Units Chgs Paid
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R 13 9.500000 351.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 41 36.500000 1439.5000 0.0000
P 3838 3385.250000 144593.8900 144529.1400
D 0 0.000000 0.0000 0.0000
S 8 8.000000 400.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
35 24.000000 982.5000 0.0000
Other 2 1.000000 37.0000 0.0000
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Total 3937 3464.250000 147804.3900 144529.1400