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
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 691 1853.000000 68533.2500 36.9850
Subtotal (Total Children Is Unduplicated) 691 1853.000000 68533.2500 36.9850
-----------------------------------------------------------------------------------------------------------------------
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 6 11.000000 825.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 11 20.500000 1137.7500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 21 33.500000 2512.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 8 15.500000 1162.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 7 11.000000 825.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 54 92.000000 5106.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 73 137.500000 10312.5000 75.0000
Subtotal (Total Children Is Unduplicated) 137 338.500000 23193.7500 68.5192
-----------------------------------------------------------------------------------------------------------------------
EI Services,Class #03
COUN-H2019HR-INDIVIDUAL/FAMILY THERAPY 3 4.000000 293.2800 73.3200
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 17 21.000000 525.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 254 1376.750000 68837.5000 50.0000
Subtotal (Total Children Is Unduplicated) 259 1401.750000 69655.7800 49.6920
-----------------------------------------------------------------------------------------------------------------------
Total 3593.250000 161382.7800 44.9128
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 735
-----------------------------------------------------------------------------------------------------------------------
Center 53
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 2 1.500000 68.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 16 13.500000 647.5000 0.0000
P 3835 3501.500000 157539.7500 157485.0000
D 0 0.000000 0.0000 0.0000
S 10 8.000000 399.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
62 68.750000 2728.0300 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 3925 3593.250000 161382.7800 157485.0000