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
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 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 21 41.500000 3112.5000 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 15 27.000000 1498.5000 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 6 11.500000 862.5000 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 77 132.000000 7326.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 85 158.000000 11812.5000 74.7627
Subtotal (Total Children Is Unduplicated) 175 468.000000 31962.0000 68.2949
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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 295 1408.250000 70412.5000 50.0000
Subtotal (Total Children Is Unduplicated) 300 1446.250000 71845.7000 49.6772
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Total 4203.750000 188427.7000 44.8237
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Number of Children (Unduplicated) With at Least One Service 834
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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
209 157.500000 7074.7000 0.0000
Other 4 2.500000 93.5000 0.0000
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Total 4509 4203.750000 188427.7000 167855.5000