CMS/EIP Fiscal Report Center: 07
Services beginning 10/01/2020 ending 12/31/2020 Date of Report:01/23/2021 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 1036 2594.250000 95885.5000 36.9608
Subtotal (Total Children Is Unduplicated) 1036 2594.250000 95885.5000 36.9608
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 3 6.000000 333.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 36 72.000000 5400.0000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 12 24.000000 1800.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 14 28.000000 2100.0000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 7 14.000000 1050.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 93 186.000000 10323.0000 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 29 58.000000 3219.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 71 148.000000 11100.0000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 28 59.500000 4462.5000 75.0000
Subtotal (Total Children Is Unduplicated) 192 595.500000 39787.5000 66.8136
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EI Services,Class #03
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 1 2.000000 100.0000 50.0000
Subtotal (Total Children Is Unduplicated) 1 2.000000 100.0000 50.0000
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Total 3191.750000 135773.0000 42.5387
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Number of Children (Unduplicated) With at Least One Service 1040
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Center 07
Flag Claims Units Chgs Paid
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R 14 20.500000 1366.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 733 599.500000 23677.0000 0.0000
P 3005 2533.250000 109216.0000 108942.2000
D 0 0.000000 0.0000 0.0000
S 1 1.000000 50.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
59 37.500000 1463.5000 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 3812 3191.750000 135773.0000 108942.2000