CMS/EIP Fiscal Report Center: 53
Services beginning 07/01/2017 ending 09/30/2017 Date of Report:11/05/2017 Page: 1
List order: No List
Payclass Filters:MED
Bill Flag Filter:RBPU
Eligibility Filter:All
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 648 1736.250000 64139.5000 36.9414
Subtotal (Total Children Is Unduplicated) 648 1736.250000 64139.5000 36.9414
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 11 21.500000 1612.5000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 4 8.000000 600.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 6 10.000000 750.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 14 26.500000 1470.7500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 11 18.500000 1312.5000 70.9459
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 4 6.500000 487.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 1 1.500000 112.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 79 123.500000 6848.7500 55.4555
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 102 171.500000 12862.5000 75.0000
Subtotal (Total Children Is Unduplicated) 161 387.500000 26057.0000 67.2439
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EI Services,Class #03
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 4 7.000000 175.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 225 938.500000 46925.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 1 1.000000 71.4400 71.4400
Subtotal (Total Children Is Unduplicated) 227 946.500000 47171.4400 49.8378
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Total 3070.250000 137367.9400 44.7416
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Number of Children (Unduplicated) With at Least One Service 744
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Center 53
Flag Claims Units Chgs Paid
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R 9 7.500000 342.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 407 295.500000 10933.5000 0.0000
P 2862 2767.250000 126091.9400 126091.9400
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 0 0.000000 0.0000 0.0000
0 0.000000 0.0000 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 3278 3070.250000 137367.9400 126091.9400