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:Program Patients
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 842 2542.750000 93953.2500 36.9495
Subtotal (Total Children Is Unduplicated) 842 2542.750000 93953.2500 36.9495
-----------------------------------------------------------------------------------------------------------------------
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 30 45.500000 3412.5000 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 17 26.000000 1950.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 138 235.500000 13070.2500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 168 311.000000 23287.5000 74.8794
Subtotal (Total Children Is Unduplicated) 245 809.500000 54795.7500 67.6909
-----------------------------------------------------------------------------------------------------------------------
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 576 3248.000000 162375.0000 49.9923
Subtotal (Total Children Is Unduplicated) 576 3286.000000 163808.2000 49.8503
-----------------------------------------------------------------------------------------------------------------------
Total 6638.250000 312557.2000 47.0843
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 939
-----------------------------------------------------------------------------------------------------------------------
Center 53
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 3 1.500000 55.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 460 384.500000 16606.5000 1470.7500
P 4136 4012.250000 181204.2500 181148.7500
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
2199 2235.000000 114478.9500 0.0000
Other 4 2.500000 93.5000 0.0000
---------------------------------------------------------
Total 6805 6638.250000 312557.2000 182638.0000