CMS/EIP Fiscal Report Center: 53
Services beginning 01/01/2016 ending 03/31/2016 Date of Report:05/12/2016 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 737 2456.000000 90344.7500 36.7853
Subtotal (Total Children Is Unduplicated) 737 2456.000000 90344.7500 36.7853
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Screening, Eval, and Assessment,Class #02
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 1 1.000000 21.8400 21.8400
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 26 51.000000 3825.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 9 16.500000 1237.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 38 71.500000 3912.7500 54.7238
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 21 35.500000 2662.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 15 28.500000 2137.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 3 4.500000 337.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 147 254.000000 14097.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 171 302.500000 22650.0000 74.8760
Subtotal (Total Children Is Unduplicated) 246 799.000000 53431.5900 66.8731
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EI Services,Class #03
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 12 17.000000 425.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 462 2441.500000 122025.0000 49.9795
Subtotal (Total Children Is Unduplicated) 464 2458.500000 122450.0000 49.8068
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Total 5713.500000 266226.3400 46.5960
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Number of Children (Unduplicated) With at Least One Service 813
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Center 53
Flag Claims Units Chgs Paid
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R 152 114.250000 4374.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 2240 2067.250000 89376.7500 111.0000
P 2054 2002.750000 93589.7500 93534.2500
D 0 0.000000 0.0000 0.0000
S 5 8.750000 551.7500 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
1459 1520.500000 78334.0900 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 5910 5713.500000 266226.3400 93645.2500