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
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 669 1965.000000 72455.2500 36.8729
Subtotal (Total Children Is Unduplicated) 669 1965.000000 72455.2500 36.8729
-----------------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 13 26.000000 1950.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 14 28.000000 2100.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 13 25.500000 1912.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 26 48.500000 2691.7500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 15 25.500000 1912.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 7 14.000000 1050.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 6 8.500000 637.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 84 144.500000 8019.7500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 106 188.500000 14137.5000 75.0000
Subtotal (Total Children Is Unduplicated) 150 509.000000 34411.5000 67.6061
-----------------------------------------------------------------------------------------------------------------------
EI Services,Class #03
COUN-H2019HR-INDIVIDUAL/FAMILY THERAPY 4 8.000000 586.5600 73.3200
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 6 14.000000 350.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 495 2650.750000 132488.5000 49.9815
Subtotal (Total Children Is Unduplicated) 495 2672.750000 133425.0600 49.9205
-----------------------------------------------------------------------------------------------------------------------
Total 5146.750000 240291.8100 46.6881
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 761
-----------------------------------------------------------------------------------------------------------------------
Center 53
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 6 4.250000 157.2500 0.0000
U 0 0.000000 0.0000 0.0000
B 550 529.750000 25699.5000 0.0000
P 2814 2660.500000 119138.5000 119138.5000
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
1883 1952.000000 95287.3100 0.0000
Other 1 0.250000 9.2500 0.0000
---------------------------------------------------------
Total 5254 5146.750000 240291.8100 119138.5000