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
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 750 678.000000 25086.0000 37.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 1419 5299.500000 196081.5000 37.0000
Subtotal (Total Children Is Unduplicated) 1473 5977.500000 221167.5000 37.0000
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Screening, Eval, and Assessment,Class #02
EVAL-96111-DEVELOPMENTAL EVALUATION 56 56.500000 2825.0000 50.0000
EXIT-EXIT-EXIT ASSESSMENT 104 107.000000 5350.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 23 17.000000 1275.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 26 23.500000 1762.5000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 11 6.500000 487.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 46 46.500000 3803.2500 81.7903
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 41 45.000000 2497.5000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 107 85.500000 6412.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 109 94.000000 7050.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 74 46.000000 3450.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 247 294.500000 16344.7500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 133 120.000000 9820.2600 81.8355
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 55 55.000000 5653.0000 102.7818
MED-99204-OUTPATIENT VISIT, NEW, 45 MINS 1 1.000000 57.2700 57.2700
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 15 15.000000 673.8200 44.9213
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 30 31.000000 1582.5500 51.0500
Subtotal (Total Children Is Unduplicated) 478 1044.000000 69044.9000 66.1350
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Total 7021.500000 290212.4000 41.3320
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Number of Children (Unduplicated) With at Least One Service 1484
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Center 04
Flag Claims Units Chgs Paid
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R 3 7.500000 277.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 61 93.500000 3459.5000 0.0000
P 2975 4227.750000 168842.6500 169168.8200
D 46 71.250000 2692.7500 0.0000
S 2 4.250000 157.2500 0.0000
H 0 0.000000 0.0000 0.0000
T 1 1.500000 55.5000 0.0000
2962 2615.750000 114727.2500 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 6050 7021.500000 290212.4000 169168.8200