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:TPIN
Eligibility Filter:Part C (excluding not eligible)
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 5 5.500000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 14 26.250000 971.2500 37.0000
Subtotal (Total Children Is Unduplicated) 18 31.750000 971.2500 30.5906
-----------------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
EXIT-EXIT-EXIT ASSESSMENT 1 1.000000 50.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 4 8.000000 600.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 6 12.000000 900.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 1 1.000000 55.5000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 4 7.000000 525.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 4 7.500000 562.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 18 31.500000 1748.2500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 19 33.000000 2512.5000 76.1364
Subtotal (Total Children Is Unduplicated) 37 101.000000 6953.7500 68.8490
-----------------------------------------------------------------------------------------------------------------------
EI Services,Class #03
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 1 1.000000 50.0000 50.0000
COUN-H2019HR-INDIVIDUAL/FAMILY THERAPY 2 2.000000 146.6400 73.3200
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 99 500.750000 25025.0000 49.9750
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 9 10.000000 100.0000 10.0000
Subtotal (Total Children Is Unduplicated) 102 513.750000 25321.6400 49.2879
-----------------------------------------------------------------------------------------------------------------------
Total 646.500000 33246.6400 51.4256
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 127
-----------------------------------------------------------------------------------------------------------------------
Center 53
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 0 0.000000 0.0000 0.0000
P 0 0.000000 0.0000 0.0000
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
599 631.250000 32484.1400 0.0000
Other 16 15.250000 762.5000 0.0000
---------------------------------------------------------
Total 615 646.500000 33246.6400 0.0000