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:TPIN
Eligibility Filter:Part C (excluding not eligible)
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
CASE-CASE-NON-TCM CASE MANAGEMENT 1 0.250000 9.2500 37.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 4 4.750000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 10 28.750000 1008.2500 35.0696
Subtotal (Total Children Is Unduplicated) 15 33.750000 1017.5000 30.1481
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Screening, Eval, and Assessment,Class #02
EXIT-EXIT-EXIT ASSESSMENT 1 1.000000 50.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 3 6.000000 450.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 2.000000 150.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 2 4.000000 262.5000 65.6250
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 3 6.000000 333.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 3 5.500000 412.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 3 5.500000 412.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 11 20.000000 1099.0000 54.9500
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 20 36.000000 2700.0000 75.0000
Subtotal (Total Children Is Unduplicated) 31 86.000000 5869.5000 68.2500
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EI Services,Class #03
COUN-H2019HR-INDIVIDUAL/FAMILY THERAPY 2 5.000000 366.6000 73.3200
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 5 11.000000 275.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 99 562.250000 28112.5000 50.0000
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 1 1.000000 50.0000 50.0000
Subtotal (Total Children Is Unduplicated) 102 579.250000 28804.1000 49.7265
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Total 699.000000 35691.1000 51.0602
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Number of Children (Unduplicated) With at Least One Service 124
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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 0 0.000000 0.0000 0.0000
P 42 39.450000 1923.7500 1188.7500
D 10 12.000000 661.0000 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
589 623.300000 31927.1000 0.0000
Other 27 24.250000 1179.2500 0.0000
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Total 668 699.000000 35691.1000 1188.7500