CMS/EIP Fiscal Report Center: 53
Services beginning 04/01/2016 ending 06/30/2016 Date of Report:08/07/2016 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 795 2557.250000 94229.7500 36.8481
Subtotal (Total Children Is Unduplicated) 795 2557.250000 94229.7500 36.8481
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 20 40.000000 3000.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 15 29.500000 2212.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 5 8.000000 600.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 34 63.000000 3496.5000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 11 20.500000 1537.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 19 31.500000 2362.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 11 16.000000 1200.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 140 235.000000 13042.5000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 141 241.000000 18075.0000 75.0000
Subtotal (Total Children Is Unduplicated) 220 684.500000 45526.5000 66.5106
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EI Services,Class #03
COUN-H2019HR-INDIVIDUAL/FAMILY THERAPY 12 25.000000 1833.0000 73.3200
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 14 38.000000 950.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 565 3842.000000 192075.0000 49.9935
Subtotal (Total Children Is Unduplicated) 566 3905.000000 194858.0000 49.8996
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Total 7146.750000 334614.2500 46.8205
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Number of Children (Unduplicated) With at Least One Service 901
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Center 53
Flag Claims Units Chgs Paid
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R 164 148.500000 5454.7500 0.0000
U 0 0.000000 0.0000 0.0000
B 1577 1577.250000 75902.5000 0.0000
P 2167 1926.500000 80545.5000 80508.5000
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
3489 3492.500000 172611.5000 200.0000
Other 2 2.000000 100.0000 0.0000
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Total 7399 7146.750000 334614.2500 80708.5000