CMS/EIP Fiscal Report Center: 53
Services beginning 07/01/2016 ending 09/30/2016 Date of Report:10/31/2016 Page: 1
List order: No List
Payclass Filters:MED
Bill Flag Filter:RBPU
Eligibility Filter:All
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 676 2006.750000 74055.5000 36.9032
Subtotal (Total Children Is Unduplicated) 676 2006.750000 74055.5000 36.9032
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 10 20.000000 1500.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 13 26.000000 1950.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 8 12.500000 937.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 17 29.500000 1637.2500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 12 19.500000 1462.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 5 9.000000 675.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 4 7.000000 525.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 95 155.000000 8602.5000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 118 205.500000 15412.5000 75.0000
Subtotal (Total Children Is Unduplicated) 187 484.000000 32702.2500 67.5666
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EI Services,Class #03
COUN-H2019HR-INDIVIDUAL/FAMILY THERAPY 18 47.000000 3446.0400 73.3200
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 5 12.000000 300.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 229 1155.250000 57762.5000 50.0000
Subtotal (Total Children Is Unduplicated) 242 1214.250000 61508.5400 50.6556
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Total 3705.000000 168266.2900 45.4160
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Number of Children (Unduplicated) With at Least One Service 748
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Center 53
Flag Claims Units Chgs Paid
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R 3 4.250000 194.2500 0.0000
U 0 0.000000 0.0000 0.0000
B 1849 1760.750000 81803.2900 0.0000
P 2057 1940.000000 86268.7500 86218.7500
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
0 0.000000 0.0000 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 3909 3705.000000 168266.2900 86218.7500