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
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 750 678.000000 25086.0000 37.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 390 1291.750000 47794.7500 37.0000
Subtotal (Total Children Is Unduplicated) 945 1969.750000 72880.7500 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 5 4.000000 300.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 8 8.500000 637.5000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 3 2.500000 187.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 16 11.500000 862.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 20 17.000000 943.5000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 26 23.500000 1762.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 29 27.000000 2025.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 20 15.500000 1162.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 154 124.000000 6882.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 42 28.000000 2100.0000 75.0000
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 13 13.000000 526.5000 40.5000
MED-99204-OUTPATIENT VISIT, NEW, 45 MINS 1 1.000000 57.2700 57.2700
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 5 5.000000 110.7000 22.1400
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 30 31.000000 1582.5500 51.0500
Subtotal (Total Children Is Unduplicated) 385 475.000000 27315.0200 57.5053
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Total 2444.750000 100195.7700 40.9841
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Number of Children (Unduplicated) With at Least One Service 1086
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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 4 2.500000 177.7500 177.7500
D 46 71.250000 2692.7500 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
2706 2371.000000 97325.2700 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 2756 2444.750000 100195.7700 177.7500