CMS/EIP Fiscal Report Center: 53
Services beginning 10/01/2015 ending 12/31/2015 Date of Report:02/13/2016 Page: 1
List order: No List
Payclass Filters:MED
Eligibility Filter:Part C (excluding not eligible)
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 648 2066.750000 75739.0000 36.6464
Subtotal (Total Children Is Unduplicated) 648 2066.750000 75739.0000 36.6464
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 17 34.000000 2550.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 11 22.000000 1650.0000 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 27 49.000000 2719.5000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 16 30.000000 2250.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 11 20.000000 1500.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 82 145.500000 8075.2500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 94 169.000000 12675.0000 75.0000
Subtotal (Total Children Is Unduplicated) 146 479.500000 32169.7500 67.0902
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EI Services,Class #03
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 6 6.000000 150.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 485 3019.250000 150962.5000 50.0000
Subtotal (Total Children Is Unduplicated) 485 3025.250000 151112.5000 49.9504
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Total 5571.500000 259021.2500 46.4904
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Number of Children (Unduplicated) With at Least One Service 727
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Center 53
Flag Claims Units Chgs Paid
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R 1 0.500000 18.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 1696 1575.000000 65186.0000 0.0000
P 1575 1553.000000 73303.0000 73367.7500
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
2466 2443.000000 120513.7500 111.0000
Other 0 0.000000 0.0000 0.0000
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Total 5738 5571.500000 259021.2500 73478.7500