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:Program Patients
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 700 2093.750000 77182.0000 36.8630
Subtotal (Total Children Is Unduplicated) 700 2093.750000 77182.0000 36.8630
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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 14 28.000000 2100.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 15 28.500000 2137.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 29 52.500000 2913.7500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 17 28.500000 2137.5000 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 7 10.500000 787.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 100 171.000000 9490.5000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 123 215.000000 16125.0000 75.0000
Subtotal (Total Children Is Unduplicated) 172 574.000000 38691.7500 67.4072
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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 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
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Total 5340.500000 249298.8100 46.6808
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Number of Children (Unduplicated) With at Least One Service 792
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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
1918 1995.250000 97330.3100 0.0000
Other 1 0.250000 9.2500 0.0000
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Total 5410 5340.500000 249298.8100 125711.0000