CMS/EIP Fiscal Report Center: 53
Services beginning 07/01/2015 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 1492 8183.250000 300884.0000 36.7683
Subtotal (Total Children Is Unduplicated) 1492 8183.250000 300884.0000 36.7683
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 60 120.000000 9000.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 56 110.500000 8287.5000 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 26 45.500000 3487.5000 76.6484
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 118 219.000000 12099.0000 55.2466
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 86 152.500000 11437.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 50 88.500000 6637.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 21 32.000000 2400.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 471 800.500000 44788.5000 55.9507
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 534 916.000000 69562.5000 75.9416
Subtotal (Total Children Is Unduplicated) 728 2485.500000 167775.0000 67.5015
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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 868 12810.50000 640362.5000 49.9873
Subtotal (Total Children Is Unduplicated) 869 12898.50000 643770.5000 49.9105
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Total 23567.250000 1112429.5000 47.2023
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Number of Children (Unduplicated) With at Least One Service 1560
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Center 53
Flag Claims Units Chgs Paid
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R 356 291.000000 10718.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 3799 3752.250000 169335.7500 3172.7500
P 10041 9416.750000 420508.2500 420425.0000
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
9912 10077.500000 510415.7500 400.0000
Other 2 2.000000 100.0000 0.0000
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Total 24112 23542.250000 1111179.5000 423997.7500