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
Agency Filter:EIP DEI DEIP
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
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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 9 18.000000 1350.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 6 11.500000 862.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 18 32.500000 1803.7500 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 6 12.000000 900.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 2 3.500000 262.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 71 121.500000 6743.2500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 77 138.500000 10387.5000 75.0000
Subtotal (Total Children Is Unduplicated) 134 389.000000 26172.0000 67.2802
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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 12.000000 300.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 256 1289.750000 64487.5000 50.0000
Subtotal (Total Children Is Unduplicated) 260 1309.750000 65374.0600 49.9134
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Total 3663.750000 164001.3100 44.7632
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Number of Children (Unduplicated) With at Least One Service 716
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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 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
451 469.000000 18996.8100 0.0000
Other 1 0.250000 9.2500 0.0000
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Total 3822 3663.750000 164001.3100 119138.5000