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:Program Patients
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 716 2354.250000 86228.5000 36.6267
Subtotal (Total Children Is Unduplicated) 716 2354.250000 86228.5000 36.6267
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 18 36.000000 2700.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 11 22.000000 1650.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 1.000000 75.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 6 12.000000 900.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 32 57.000000 3163.5000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 24 43.000000 3225.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 11 20.000000 1500.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 1 1.500000 112.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 111 194.000000 10711.5000 55.2139
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 133 230.500000 17287.5000 75.0000
Subtotal (Total Children Is Unduplicated) 191 617.000000 41325.0000 66.9773
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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 487 3026.250000 151312.5000 50.0000
Subtotal (Total Children Is Unduplicated) 487 3032.250000 151462.5000 49.9505
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Total 6003.500000 279016.0000 46.4756
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Number of Children (Unduplicated) With at Least One Service 796
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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 1845 1741.750000 72330.5000 0.0000
P 1726 1715.250000 80961.5000 81026.2500
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
2547 2546.000000 125705.5000 111.0000
Other 0 0.000000 0.0000 0.0000
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Total 6119 6003.500000 279016.0000 81137.2500