CMS/EIP Fiscal Report Center: 07
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 1091 2762.500000 101870.2500 36.8761
Subtotal (Total Children Is Unduplicated) 1091 2762.500000 101870.2500 36.8761
-----------------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 8 16.000000 1200.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 5 10.000000 750.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 6 12.000000 666.0000 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 113 225.000000 12487.5000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 98 193.000000 14475.0000 75.0000
SCREEN-T1023-SCREENING 5 5.000000 250.0000 50.0000
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 2 4.000000 204.2000 51.0500
Subtotal (Total Children Is Unduplicated) 213 643.000000 43382.7000 67.4692
-----------------------------------------------------------------------------------------------------------------------
EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 1 1.000000 50.0000 50.0000
Subtotal (Total Children Is Unduplicated) 1 1.000000 50.0000 50.0000
-----------------------------------------------------------------------------------------------------------------------
Total 3406.500000 145302.9500 42.6546
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 1102
-----------------------------------------------------------------------------------------------------------------------
Center 07
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 10 10.750000 397.7500 0.0000
U 0 0.000000 0.0000 0.0000
B 2111 1841.250000 78632.4500 129.5000
P 1454 1418.000000 60926.2500 61085.0000
D 1 0.250000 9.2500 0.0000
S 4 5.500000 316.5000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
176 130.750000 5020.7500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 3756 3406.500000 145302.9500 61214.5000