CMS/EIP Fiscal Report Center: 07
Services beginning 10/01/2019 ending 12/31/2019 Date of Report:02/01/2020 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 1150 2846.250000 105089.2500 36.9220
Subtotal (Total Children Is Unduplicated) 1150 2846.250000 105089.2500 36.9220
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 1 2.000000 150.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 2 4.000000 222.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 101 201.000000 15075.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 106 210.500000 11682.7500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 108 230.500000 17287.5000 75.0000
SCREEN-T1023-SCREENING 8 10.000000 500.0000 50.0000
Subtotal (Total Children Is Unduplicated) 209 658.000000 44917.2500 68.2633
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Total 3504.250000 150006.5000 42.8070
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Number of Children (Unduplicated) With at Least One Service 1159
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Center 07
Flag Claims Units Chgs Paid
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R 120 133.500000 4952.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 620 536.250000 21968.5000 0.0000
P 3011 2749.000000 119809.0000 119836.4500
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
114 85.500000 3276.5000 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 3865 3504.250000 150006.5000 119836.4500