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
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 665 572.500000 21182.5000 37.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 1335 5609.750000 207560.7500 37.0000
Subtotal (Total Children Is Unduplicated) 1382 6182.250000 228743.2500 37.0000
-----------------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
EVAL-96111-DEVELOPMENTAL EVALUATION 69 73.500000 3675.0000 50.0000
EXIT-EXIT-EXIT ASSESSMENT 71 75.000000 3750.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 14 9.500000 712.5000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 21 16.500000 1237.5000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 5 3.000000 225.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 27 31.500000 2362.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 44 52.000000 2886.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 62 38.500000 2887.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 36 26.000000 1950.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 108 72.000000 5400.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 314 387.000000 21478.5000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 167 144.000000 10800.0000 75.0000
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 59 59.000000 3707.0000 62.8305
MED-99204-OUTPATIENT VISIT, NEW, 45 MINS 1 1.000000 57.2700 57.2700
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 12 12.000000 436.5400 36.3783
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 1 2.000000 102.1000 51.0500
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 1 1.000000 51.0500 51.0500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 7 7.000000 357.3500 51.0500
Subtotal (Total Children Is Unduplicated) 512 1010.500000 62075.8100 61.4308
-----------------------------------------------------------------------------------------------------------------------
Total 7192.750000 290819.0600 40.4322
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 1389
-----------------------------------------------------------------------------------------------------------------------
Center 04
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 136 186.750000 7897.7500 0.0000
P 2687 3998.500000 155449.6400 155958.1900
D 45 62.500000 2312.5000 0.0000
S 2 4.250000 157.2500 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
3084 2940.750000 125001.9200 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 5954 7192.750000 290819.0600 155958.1900