CMS/EIP Fiscal Report Center: 04
Services beginning 10/01/2015 ending 12/31/2015 Date of Report:02/13/2016 Page: 1
List order: No List
Eligibility Filter:Not Part C
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
CASE-CASE-NON-TCM CASE MANAGEMENT 40 43.250000 1600.2500 37.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 80 390.750000 14457.7500 37.0000
Subtotal (Total Children Is Unduplicated) 80 434.000000 16058.0000 37.0000
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 1.000000 75.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 2 1.500000 112.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 1 1.000000 75.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 3 3.000000 166.5000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 24 13.500000 1012.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 3 2.000000 150.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 19 11.000000 825.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 53 57.500000 3191.2500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 25 24.000000 2862.5000 119.2708
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 11 11.000000 1451.5000 131.9545
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 2 2.000000 102.1000 51.0500
Subtotal (Total Children Is Unduplicated) 61 127.500000 10023.8500 78.6184
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Total 561.500000 26081.8500 46.4503
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Number of Children (Unduplicated) With at Least One Service 80
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Center 04
Flag Claims Units Chgs Paid
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R 1 0.250000 9.2500 0.0000
U 0 0.000000 0.0000 0.0000
B 24 47.000000 1776.5000 0.0000
P 104 152.500000 8260.7500 7883.2900
D 1 4.500000 166.5000 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
291 357.250000 15868.8500 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 421 561.500000 26081.8500 7883.2900