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
Payclass Filters:GR
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 445 1630.000000 60310.0000 37.0000
Subtotal (Total Children Is Unduplicated) 899 2202.500000 81492.5000 37.0000
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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 1 1.000000 75.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 0.500000 37.5000 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 5 4.500000 337.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 20 14.500000 804.7500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 19 14.000000 1050.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 7 6.500000 487.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 29 22.000000 1650.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 211 170.000000 9435.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 41 26.500000 1987.5000 75.0000
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 40 40.000000 1620.0000 40.5000
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 9 9.000000 199.2600 22.1400
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) 396 468.500000 25732.0100 54.9242
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Total 2671.000000 107224.5100 40.1440
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Number of Children (Unduplicated) With at Least One Service 1046
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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 1 4.000000 148.0000 0.0000
P 0 0.000000 0.0000 0.0000
D 44 61.750000 2284.7500 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
2748 2605.250000 104791.7600 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 2793 2671.000000 107224.5100 0.0000