CMS/EIP Fiscal Report Center: 53
Services beginning 10/01/2018 ending 12/31/2018 Date of Report:02/06/2019 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 684 1803.000000 66535.7500 36.9028
Subtotal (Total Children Is Unduplicated) 684 1803.000000 66535.7500 36.9028
-----------------------------------------------------------------------------------------------------------------------
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 9 18.000000 1350.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 1.500000 112.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 7 13.000000 975.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 12 22.500000 1248.7500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 30 51.500000 3862.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 15 24.500000 1837.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 19 29.500000 2212.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 82 137.000000 7603.5000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 70 129.500000 9675.0000 74.7104
Subtotal (Total Children Is Unduplicated) 177 448.500000 30489.7500 67.9816
-----------------------------------------------------------------------------------------------------------------------
EI Services,Class #03
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 14 21.000000 525.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 268 1352.000000 67600.0000 50.0000
Subtotal (Total Children Is Unduplicated) 274 1373.000000 68125.0000 49.6176
-----------------------------------------------------------------------------------------------------------------------
Total 3624.500000 165150.5000 45.5650
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 765
-----------------------------------------------------------------------------------------------------------------------
Center 53
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 21 18.500000 739.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 773 715.500000 29755.7500 2.0000
P 2656 2680.500000 125552.7500 125515.7500
D 0 0.000000 0.0000 0.0000
S 17 17.750000 720.5000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
209 190.250000 8282.0000 0.0000
Other 2 2.000000 100.0000 0.0000
---------------------------------------------------------
Total 3678 3624.500000 165150.5000 125517.7500