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
Payclass Filters:GR
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 32 151.500000 5605.5000 37.0000
Subtotal (Total Children Is Unduplicated) 57 192.250000 7113.2500 37.0000
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Screening, Eval, and Assessment,Class #02
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 6 3.500000 262.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 6 5.000000 375.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 37 31.500000 1748.2500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 5 3.000000 225.0000 75.0000
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 10 10.000000 405.0000 40.5000
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 1 1.000000 51.0500 51.0500
Subtotal (Total Children Is Unduplicated) 45 54.000000 3066.8000 56.7926
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Total 246.250000 10180.0500 41.3403
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Number of Children (Unduplicated) With at Least One Service 65
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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 0 0.000000 0.0000 0.0000
P 0 0.000000 0.0000 0.0000
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
216 242.500000 10041.3000 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 217 246.250000 10180.0500 0.0000