CMS/EIP Fiscal Report Center: 07
Services beginning 01/01/2023 ending 03/31/2023 Date of Report:04/20/2023 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 1008 1951.250000 72586.5000 37.2000
Subtotal (Total Children Is Unduplicated) 1008 1951.250000 72586.5000 37.2000
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 2 4.000000 300.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 3 6.000000 450.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 3 6.000000 333.0000 55.5000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 8 16.000000 888.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 40 80.000000 6000.0000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 22 44.000000 3300.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 45 90.000000 6750.0000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 13 26.000000 1950.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 76 152.000000 8436.0000 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 40 80.000000 4440.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 36 72.000000 5400.0000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 8 16.000000 1200.0000 75.0000
SCREEN-T1023-SCREENING 1 1.000000 50.0000 50.0000
Subtotal (Total Children Is Unduplicated) 203 593.000000 39497.0000 66.6054
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Total 2544.250000 112083.5000 44.0537
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Number of Children (Unduplicated) With at Least One Service 1047
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Center 07
Flag Claims Units Chgs Paid
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R 7 6.000000 223.2000 0.0000
U 0 0.000000 0.0000 0.0000
B 944 852.000000 39189.6000 0.0000
P 1804 1555.750000 67578.9000 67439.4000
D 0 0.000000 0.0000 0.0000
S 1 0.500000 18.6000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
30 18.500000 688.2000 0.0000
Other 184 111.500000 4385.0000 0.0000
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Total 2970 2544.250000 112083.5000 67439.4000