CMS/EIP Fiscal Report Center: 04
Services beginning 10/01/2016 ending 12/31/2016 Date of Report:02/04/2017 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 36.250000 1341.2500 37.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 73 416.500000 15410.5000 37.0000
Subtotal (Total Children Is Unduplicated) 74 452.750000 16751.7500 37.0000
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Screening, Eval, and Assessment,Class #02
EVAL-96111-DEVELOPMENTAL EVALUATION 1 0.750000 37.5000 50.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 0.500000 37.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 1 1.000000 55.5000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 36 28.000000 2100.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 28 22.000000 1650.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 9 6.000000 450.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 62 71.000000 3940.5000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 22 19.500000 1462.5000 75.0000
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 8 8.000000 587.5000 73.4375
Subtotal (Total Children Is Unduplicated) 67 156.750000 10321.0000 65.8437
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 1 3.000000 150.0000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 1 3.000000 30.0000 10.0000
Subtotal (Total Children Is Unduplicated) 1 6.000000 180.0000 30.0000
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Total 615.500000 27252.7500 44.2774
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Number of Children (Unduplicated) With at Least One Service 74
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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 3 7.750000 286.7500 0.0000
P 239 407.500000 17520.2500 17623.3700
D 3 8.500000 314.5000 0.0000
S 0 0.000000 0.0000 0.0000
H 2 3.000000 150.0000 0.0000
T 0 0.000000 0.0000 0.0000
205 188.750000 8981.2500 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 452 615.500000 27252.7500 17623.3700