CMS/EIP Fiscal Report Center: 04
Services beginning 01/01/2016 ending 03/31/2016 Date of Report:05/12/2016 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 45 40.750000 1507.7500 37.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 75 427.500000 15817.5000 37.0000
Subtotal (Total Children Is Unduplicated) 75 468.250000 17325.2500 37.0000
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Screening, Eval, and Assessment,Class #02
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 12 7.500000 562.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 6 4.500000 337.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 22 14.000000 1050.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 64 71.000000 3940.5000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 34 32.500000 2437.5000 75.0000
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 12 12.000000 749.5000 62.4583
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 1 1.000000 51.0500 51.0500
Subtotal (Total Children Is Unduplicated) 65 142.500000 9128.5500 64.0600
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Total 610.750000 26453.8000 43.3136
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Number of Children (Unduplicated) With at Least One Service 75
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Center 04
Flag Claims Units Chgs Paid
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R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 8 15.000000 688.0000 0.0000
P 191 322.750000 13550.0000 13963.2400
D 1 3.750000 138.7500 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
247 269.250000 12077.0500 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 447 610.750000 26453.8000 13963.2400