CMS/EIP Fiscal Report Center: 54
Services beginning 10/01/2017 ending 12/31/2017 Date of Report:02/03/2018 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 1113 3288.000000 121064.0000 36.8200
Subtotal (Total Children Is Unduplicated) 1113 3288.000000 121064.0000 36.8200
-----------------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 22 40.000000 3000.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 9 14.500000 1087.5000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 2 3.500000 262.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 11 22.000000 1650.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 4 6.000000 333.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 121 207.000000 15450.0000 74.6377
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 36 49.500000 3712.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 6 8.500000 637.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 47 70.000000 3885.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 36 59.500000 4462.5000 75.0000
SCREEN-T1023-SCREENING 6 6.000000 300.0000 50.0000
Subtotal (Total Children Is Unduplicated) 207 486.500000 34780.5000 71.4913
-----------------------------------------------------------------------------------------------------------------------
EI Services,Class #03
COUN-H2019HR-INDIVIDUAL/FAMILY THERAPY 1 4.000000 293.2800 73.3200
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 230 1173.500000 58675.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 2 4.000000 285.7600 71.4400
PHY-97110-PT SESSION BY LICENSED PT 6 15.000000 1071.6000 71.4400
Subtotal (Total Children Is Unduplicated) 234 1196.500000 60325.6400 50.4184
-----------------------------------------------------------------------------------------------------------------------
Total 4971.000000 216170.1400 43.4862
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 1125
-----------------------------------------------------------------------------------------------------------------------
Center 54
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 1385 1119.750000 47042.2500 0.0000
U 0 0.000000 0.0000 0.0000
B 3048 2463.750000 108226.8500 0.0000
P 0 0.000000 0.0000 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 0 0.000000 0.0000 0.0000
1560 1387.500000 60901.0400 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 5993 4971.000000 216170.1400 0.0000