CMS/EIP Fiscal Report Center: 53
Services beginning 04/01/2018 ending 06/30/2018 Date of Report:08/10/2018 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 735 2019.750000 74703.0000 36.9863
Subtotal (Total Children Is Unduplicated) 735 2019.750000 74703.0000 36.9863
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 4 8.000000 600.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 5 9.500000 712.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 10 18.500000 1387.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 14 26.000000 1443.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 27 42.500000 3187.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 12 21.000000 1575.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 10 14.500000 1087.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 73 120.500000 6687.7500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 100 190.000000 14250.0000 75.0000
Subtotal (Total Children Is Unduplicated) 181 450.500000 30930.7500 68.6587
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EI Services,Class #03
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 17 21.000000 525.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 255 1371.750000 68587.5000 50.0000
Subtotal (Total Children Is Unduplicated) 259 1392.750000 69112.5000 49.6230
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Total 3863.000000 174746.2500 45.2359
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Number of Children (Unduplicated) With at Least One Service 790
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Center 53
Flag Claims Units Chgs Paid
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R 2 1.500000 68.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 17 13.750000 656.7500 9.2500
P 4163 3847.750000 174021.0000 173966.2500
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 4182 3863.000000 174746.2500 173975.5000