CMS/EIP Fiscal Report Center: 54
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 1027 3024.000000 111804.7500 36.9725
Subtotal (Total Children Is Unduplicated) 1027 3024.000000 111804.7500 36.9725
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 18 31.000000 2325.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 13 19.500000 1462.5000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 2 2.500000 187.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 10 16.500000 1237.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 12 16.000000 888.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 134 218.500000 16350.0000 74.8284
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 70 106.500000 7987.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 8 10.500000 787.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 76 110.500000 6077.2500 54.9977
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 45 73.000000 5475.0000 75.0000
SCREEN-T1023-SCREENING 7 7.000000 350.0000 50.0000
Subtotal (Total Children Is Unduplicated) 288 611.500000 43127.7500 70.5278
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EI Services,Class #03
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 2 2.000000 50.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 310 1415.000000 70725.0000 49.9823
Subtotal (Total Children Is Unduplicated) 310 1417.000000 70775.0000 49.9471
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Total 5052.500000 225707.5000 44.6724
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Number of Children (Unduplicated) With at Least One Service 1073
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Center 54
Flag Claims Units Chgs Paid
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R 3 2.000000 74.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 5199 4305.500000 185784.0000 50.0000
P 721 745.000000 39849.5000 39865.2500
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 5923 5052.500000 225707.5000 39915.2500