CMS/EIP Fiscal Report Center: 53
Services beginning 01/01/2017 ending 03/31/2017 Date of Report:05/05/2017 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 774 2222.750000 82109.9400 36.9407
Subtotal (Total Children Is Unduplicated) 774 2222.750000 82109.9400 36.9407
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 7 13.000000 975.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 10 20.000000 1500.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 1.500000 112.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 8 15.500000 1162.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 26 47.000000 2608.5000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 4 8.000000 600.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 11 20.000000 1500.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 6 12.000000 900.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 79 133.000000 7381.5000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 90 157.500000 11812.5000 75.0000
Subtotal (Total Children Is Unduplicated) 160 427.500000 28552.5000 66.7895
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EI Services,Class #03
COUN-H2019HR-INDIVIDUAL/FAMILY THERAPY 4 7.000000 513.2400 73.3200
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 7 18.000000 450.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 260 1289.750000 64487.5000 50.0000
Subtotal (Total Children Is Unduplicated) 266 1314.750000 65450.7400 49.7819
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Total 3965.000000 176113.1800 44.4169
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Number of Children (Unduplicated) With at Least One Service 813
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Center 53
Flag Claims Units Chgs Paid
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R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 133 137.250000 6642.2500 0.0000
P 3754 3492.750000 156570.7500 156570.7500
D 0 0.000000 0.0000 0.0000
S 447 315.750000 11615.6900 11615.6900
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
17 19.250000 1284.4900 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 4351 3965.000000 176113.1800 168186.4400