CMS/EIP Fiscal Report Center: 04
Services beginning 01/01/2017 ending 03/31/2017 Date of Report:05/05/2017 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 56 43.500000 1609.5000 37.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 100 569.500000 21071.5000 37.0000
Subtotal (Total Children Is Unduplicated) 102 613.000000 22681.0000 37.0000
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Screening, Eval, and Assessment,Class #02
EVAL-96111-DEVELOPMENTAL EVALUATION 1 0.500000 25.0000 50.0000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 32 24.500000 1837.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 26 20.000000 1500.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 27 15.500000 1162.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 72 75.500000 4190.2500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 51 49.000000 3839.7000 78.3612
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 13 13.000000 1382.2500 106.3269
Subtotal (Total Children Is Unduplicated) 88 198.000000 13937.2000 70.3899
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 1 13.000000 650.0000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 1 13.000000 130.0000 10.0000
PHY-97110-PT SESSION BY LICENSED PT 1 1.500000 107.1600 71.4400
Subtotal (Total Children Is Unduplicated) 2 27.500000 887.1600 32.2604
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Total 838.500000 37505.3600 44.7291
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Number of Children (Unduplicated) With at Least One Service 102
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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 54 68.000000 3185.7500 0.0000
P 182 325.750000 12942.4500 12942.4500
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 3 13.000000 650.0000 0.0000
T 0 0.000000 0.0000 0.0000
390 430.250000 20620.0000 0.0000
Other 1 1.500000 107.1600 0.0000
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Total 630 838.500000 37505.3600 12942.4500