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
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 717 2169.500000 79910.7500 36.8337
Subtotal (Total Children Is Unduplicated) 717 2169.500000 79910.7500 36.8337
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 13 25.500000 1912.5000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 14 27.500000 2062.5000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 1.500000 112.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 7 11.000000 825.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 27 49.000000 2719.5000 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 8 14.500000 1087.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 12 16.500000 1237.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 96 162.500000 9018.7500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 117 212.500000 15937.5000 75.0000
Subtotal (Total Children Is Unduplicated) 180 540.000000 36375.7500 67.3625
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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 8 15.000000 375.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 513 2645.750000 132262.5000 49.9906
Subtotal (Total Children Is Unduplicated) 515 2707.750000 136083.5400 50.2571
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Total 5417.250000 252370.0400 46.5864
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Number of Children (Unduplicated) With at Least One Service 805
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Center 53
Flag Claims Units Chgs Paid
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R 2 2.250000 83.2500 0.0000
U 0 0.000000 0.0000 0.0000
B 1785 1691.500000 78371.5400 0.0000
P 1900 1749.000000 77322.0000 77272.0000
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
1903 1974.500000 96593.2500 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 5590 5417.250000 252370.0400 77272.0000