CMS/EIP Fiscal Report Center: 53
Services beginning 04/01/2017 ending 06/30/2017 Date of Report:08/05/2017 Page: 1
List order: No List
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 781 2289.500000 84620.0000 36.9600
Subtotal (Total Children Is Unduplicated) 781 2289.500000 84620.0000 36.9600
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 14 28.000000 2100.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 30 59.000000 4425.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 10 19.000000 1425.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 33 66.000000 3663.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 20 31.500000 2362.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 11 19.500000 1462.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 12 19.500000 1462.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 104 184.000000 10212.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 125 236.500000 17700.0000 74.8414
Subtotal (Total Children Is Unduplicated) 194 663.000000 44812.5000 67.5905
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EI Services,Class #03
COUN-H2019HR-INDIVIDUAL/FAMILY THERAPY 5 10.000000 733.2000 73.3200
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 8 28.000000 700.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 575 3247.000000 162325.0000 49.9923
Subtotal (Total Children Is Unduplicated) 575 3285.000000 163758.2000 49.8503
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Total 6237.500000 293190.7000 47.0045
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Number of Children (Unduplicated) With at Least One Service 878
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Center 53
Flag Claims Units Chgs Paid
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R 1 0.500000 18.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 427 347.500000 14617.5000 1387.5000
P 3865 3693.250000 166505.0000 166449.5000
D 0 0.000000 0.0000 0.0000
S 3 2.500000 118.5000 18.5000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
2162 2191.250000 111837.7000 0.0000
Other 4 2.500000 93.5000 0.0000
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Total 6462 6237.500000 293190.7000 167855.5000