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:GR
Eligibility Filter:Program Patients
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
CASE-CASE-NON-TCM CASE MANAGEMENT 835 1167.250000 43132.7500 36.9525
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 930 2923.250000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 289 788.000000 29054.2500 36.8709
Subtotal (Total Children Is Unduplicated) 1193 4878.500000 72187.0000 14.7970
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Screening, Eval, and Assessment,Class #02
EVAL-96111-DEVELOPMENTAL EVALUATION 1 2.000000 100.0000 50.0000
EXIT-EXIT-EXIT ASSESSMENT 11 15.250000 762.5000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 11 11.000000 825.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 23 23.000000 1725.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 11 11.000000 610.5000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 4 6.500000 487.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 2 3.000000 225.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 2 3.500000 262.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 13 22.500000 1248.7500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 10 15.751822 1181.3867 75.0000
Subtotal (Total Children Is Unduplicated) 59 113.501822 7428.1367 65.4451
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 87 93.500000 4637.5000 49.5989
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 4 1.750000 43.7500 25.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 330 773.000000 38618.5000 49.9592
CONIP-CONIP-CONSULT, ITDS PHONE 41 18.500000 462.5000 25.0000
CONSP-CONSP-CONSULT, SLP, PHONE 1 1.000000 25.0000 25.0000
COUN-H2019HR-INDIVIDUAL/FAMILY THERAPY 9 17.000000 1246.4400 73.3200
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 7 13.500000 337.5000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 42 165.500000 8275.0000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 882 6803.500000 68005.0000 9.9956
TRAV-TRAVS-Travel by mile 457 43436.00000 19332.0100 0.4451
Subtotal (Total Children Is Unduplicated) 882 51323.25000 140983.2000 2.7470
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Total 56315.251822 220598.3367 3.9172
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Number of Children (Unduplicated) With at Least One Service 1251
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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 2 1.250000 59.2500 0.0000
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 5989 46738.001822 65750.1467 65750.1500
12595 9576.000000 154788.9400 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 18586 56315.251822 220598.3367 65750.1500