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
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 804 806.750000 29849.7500 37.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 1608 7315.250000 270664.2500 37.0000
Subtotal (Total Children Is Unduplicated) 1642 8122.000000 300514.0000 37.0000
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Screening, Eval, and Assessment,Class #02
EVAL-96111-DEVELOPMENTAL EVALUATION 60 67.000000 3350.0000 50.0000
EXIT-EXIT-EXIT ASSESSMENT 112 123.750000 6187.5000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 27 19.000000 1425.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 20 15.000000 1125.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 17 10.000000 750.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 47 59.500000 4462.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 48 50.500000 2802.7500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 168 129.000000 9675.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 154 123.000000 9225.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 94 61.000000 4575.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 355 400.500000 22227.7500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 259 270.500000 21189.3700 78.3341
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 81 81.000000 7012.8800 86.5788
MED-99204-OUTPATIENT VISIT, NEW, 45 MINS 1 1.000000 75.7200 75.7200
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 15 15.000000 880.4400 58.6960
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 26 26.000000 1327.3000 51.0500
Subtotal (Total Children Is Unduplicated) 669 1451.750000 96291.2100 66.3277
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Total 9573.750000 396805.2100 41.4472
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Number of Children (Unduplicated) With at Least One Service 1649
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Center 04
Flag Claims Units Chgs Paid
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R 1 1.000000 55.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 695 897.750000 39948.0000 0.0000
P 3141 4728.750000 187329.0900 187493.6000
D 81 106.250000 3968.7500 0.0000
S 2 2.000000 74.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
4006 3838.000000 165429.8700 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 7926 9573.750000 396805.2100 187493.6000