CMS/EIP Fiscal Report Center: 53
Services beginning 07/01/2015 ending 06/30/2016 Date of Report:08/06/2016 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 1302 7206.750000 264883.0000 36.7548
Subtotal (Total Children Is Unduplicated) 1302 7206.750000 264883.0000 36.7548
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 54 108.000000 8100.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 56 110.500000 8287.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 22 38.500000 2962.5000 76.9481
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 108 202.000000 11211.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 64 117.000000 8775.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 41 72.500000 5437.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 15 23.000000 1725.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 351 600.500000 33633.0000 56.0083
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 387 679.000000 51675.0000 76.1046
Subtotal (Total Children Is Unduplicated) 549 1951.000000 131806.5000 67.5584
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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 26 63.000000 1575.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 861 12761.75000 637925.0000 49.9873
Subtotal (Total Children Is Unduplicated) 862 12849.75000 641333.0000 49.9102
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Total 22007.500000 1038022.5000 47.1668
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Number of Children (Unduplicated) With at Least One Service 1355
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Center 53
Flag Claims Units Chgs Paid
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R 315 256.500000 9441.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 3523 3439.750000 154073.5000 3172.7500
P 9179 8481.500000 378706.7500 378623.5000
D 0 0.000000 0.0000 0.0000
S 2 2.750000 101.7500 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
9710 9800.000000 494349.0000 400.0000
Other 2 2.000000 100.0000 0.0000
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Total 22731 21982.500000 1036772.5000 382196.2500