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
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 973 2818.750000 104219.7500 36.9737
Subtotal (Total Children Is Unduplicated) 973 2818.750000 104219.7500 36.9737
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 16 27.500000 2062.5000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 9 13.500000 1012.5000 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 9 15.000000 1125.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 9 12.500000 693.7500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 88 146.000000 10912.5000 74.7432
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 51 78.500000 5887.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 7 10.000000 750.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 59 90.000000 4939.5000 54.8833
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 35 59.500000 4462.5000 75.0000
SCREEN-T1023-SCREENING 5 5.000000 250.0000 50.0000
Subtotal (Total Children Is Unduplicated) 204 460.000000 32283.2500 70.1810
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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 311 1432.000000 71575.0000 49.9825
Subtotal (Total Children Is Unduplicated) 311 1434.000000 71625.0000 49.9477
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Total 4712.750000 208128.0000 44.1628
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Number of Children (Unduplicated) With at Least One Service 1005
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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 4712 3815.000000 163983.5000 50.0000
P 672 682.750000 35758.7500 35774.5000
D 0 0.000000 0.0000 0.0000
S 1 0.250000 9.2500 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
275 210.000000 8200.7500 0.0000
Other 4 2.750000 101.7500 0.0000
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Total 5667 4712.750000 208128.0000 35824.5000