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:Program Patients
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 765 2382.250000 87745.5000 36.8330
Subtotal (Total Children Is Unduplicated) 765 2382.250000 87745.5000 36.8330
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 14 27.500000 2062.5000 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 11 17.000000 1275.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 34 60.000000 3330.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 17 27.000000 2025.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 9 16.000000 1200.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 14 20.000000 1500.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 122 202.000000 11211.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 147 263.000000 19725.0000 75.0000
Subtotal (Total Children Is Unduplicated) 223 661.500000 44503.5000 67.2766
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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 5751.500000 268332.5400 46.6544
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Number of Children (Unduplicated) With at Least One Service 855
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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 1 1.000000 37.0000 0.0000
1962 2045.500000 100029.2500 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 5872 5751.500000 268332.5400 86218.7500