CMS/EIP Fiscal Report Center: 03
Services beginning 07/01/2019 ending 09/30/2019 Date of Report:11/04/2019 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 828 2023.000000 74841.7500 36.9954
Subtotal (Total Children Is Unduplicated) 828 2023.000000 74841.7500 36.9954
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 11 24.500000 1837.5000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 3 6.000000 450.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 3 5.500000 412.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 2 4.000000 300.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 7 12.500000 693.7500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 82 143.000000 10725.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 9 15.000000 1125.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 27 44.500000 3337.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 55 97.500000 5411.2500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 20 34.500000 2587.5000 75.0000
SCREEN-T1023-SCREENING 21 23.000000 1150.0000 50.0000
Subtotal (Total Children Is Unduplicated) 133 410.000000 28030.0000 68.3659
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 27 78.000000 3900.0000 50.0000
Subtotal (Total Children Is Unduplicated) 27 78.000000 3900.0000 50.0000
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Total 2511.000000 106771.7500 42.5216
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Number of Children (Unduplicated) With at Least One Service 840
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Center 03
Flag Claims Units Chgs Paid
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R 83 57.000000 2109.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 3491 2450.000000 104438.7500 0.0000
P 2 0.750000 27.7500 27.7500
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
2 3.250000 196.2500 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 3578 2511.000000 106771.7500 27.7500