CMS/EIP Fiscal Report Center: 53
Services beginning 10/01/2016 ending 12/31/2016 Date of Report:02/04/2017 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 601 1679.250000 61873.2500 36.8458
Subtotal (Total Children Is Unduplicated) 601 1679.250000 61873.2500 36.8458
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 9 18.000000 1350.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 9 18.000000 1350.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 7 13.000000 975.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 21 36.500000 2025.7500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 11 18.500000 1387.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 6 12.000000 900.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 3 5.500000 412.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 83 140.500000 7797.7500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 90 160.000000 12000.0000 75.0000
Subtotal (Total Children Is Unduplicated) 144 422.000000 28198.5000 66.8211
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EI Services,Class #03
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 6 12.000000 300.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 249 1231.750000 61587.5000 50.0000
Subtotal (Total Children Is Unduplicated) 252 1243.750000 61887.5000 49.7588
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Total 3345.000000 151959.2500 45.4288
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Number of Children (Unduplicated) With at Least One Service 678
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Center 53
Flag Claims Units Chgs Paid
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R 6 4.250000 157.2500 0.0000
U 0 0.000000 0.0000 0.0000
B 554 535.750000 26091.0000 0.0000
P 2931 2805.000000 125711.0000 125711.0000
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
0 0.000000 0.0000 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 3491 3345.000000 151959.2500 125711.0000