CMS/EIP Fiscal Report Center: 53
Services beginning 07/01/2018 ending 09/30/2018 Date of Report:11/06/2018 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 620 1600.750000 59153.7500 36.9538
Subtotal (Total Children Is Unduplicated) 620 1600.750000 59153.7500 36.9538
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 13 23.000000 1725.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 12 23.500000 1762.5000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 2.000000 150.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 9 20.000000 1500.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 9 16.000000 888.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 17 31.000000 2325.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 3 5.000000 375.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 12 16.000000 1200.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 66 114.500000 6354.7500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 81 144.000000 10762.5000 74.7396
Subtotal (Total Children Is Unduplicated) 149 395.000000 27042.7500 68.4627
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EI Services,Class #03
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 9 9.250000 231.2500 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 266 1404.500000 70175.0000 49.9644
Subtotal (Total Children Is Unduplicated) 270 1413.750000 70406.2500 49.8011
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Total 3409.500000 156602.7500 45.9313
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Number of Children (Unduplicated) With at Least One Service 709
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Center 53
Flag Claims Units Chgs Paid
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R 160 157.000000 7242.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 987 920.750000 41556.2500 0.0000
P 2347 2236.250000 102809.0000 102598.0000
D 0 0.000000 0.0000 0.0000
S 1 0.500000 18.5000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
81 92.000000 4776.5000 0.0000
Other 2 3.000000 200.0000 0.0000
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Total 3578 3409.500000 156602.7500 102598.0000