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
Agency Filter:EIP DEI DEIP
Eligibility Filter:Part C (excluding not eligible)
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
CASE-CASE-NON-TCM CASE MANAGEMENT 625 556.500000 20590.5000 37.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 1307 4993.000000 184741.0000 37.0000
Subtotal (Total Children Is Unduplicated) 1355 5549.500000 205331.5000 37.0000
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Screening, Eval, and Assessment,Class #02
EVAL-96111-DEVELOPMENTAL EVALUATION 55 52.000000 2575.0000 49.5192
EXIT-EXIT-EXIT ASSESSMENT 92 95.250000 4762.5000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 12 6.500000 487.5000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 17 13.500000 1012.5000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 10 6.500000 487.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 27 26.000000 2602.5000 100.0962
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 46 51.000000 2830.5000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 99 57.500000 4312.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 22 16.500000 1237.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 119 80.000000 6000.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 283 324.500000 18009.7500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 137 127.000000 13030.0000 102.5984
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 65 65.000000 5890.0000 90.6154
MED-99204-OUTPATIENT VISIT, NEW, 45 MINS 4 4.000000 678.8100 169.7025
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 15 15.000000 589.9600 39.3307
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 9 10.000000 510.5000 51.0500
Subtotal (Total Children Is Unduplicated) 498 950.250000 65017.0200 68.4210
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 5 3.000000 150.0000 50.0000
Subtotal (Total Children Is Unduplicated) 5 3.000000 150.0000 50.0000
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Total 6502.750000 270498.5200 41.5976
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Number of Children (Unduplicated) With at Least One Service 1368
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Center 04
Flag Claims Units Chgs Paid
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R 53 66.750000 2469.7500 0.0000
U 0 0.000000 0.0000 0.0000
B 552 742.000000 28170.5000 0.0000
P 1806 2489.000000 105028.3000 103403.6600
D 27 43.000000 1647.5000 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
3182 3161.750000 133173.2200 43.1800
Other 1 0.250000 9.2500 0.0000
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Total 5621 6502.750000 270498.5200 103446.8400