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
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 804 806.750000 29849.7500 37.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 446 1832.250000 67793.2500 37.0000
Subtotal (Total Children Is Unduplicated) 1011 2639.000000 97643.0000 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 8 5.500000 412.5000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 3 2.000000 150.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 2 1.000000 75.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 12 9.500000 712.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 30 22.500000 1248.7500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 28 21.000000 1575.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 32 28.000000 2100.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 20 13.000000 975.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 216 155.500000 8630.2500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 60 46.000000 3450.0000 75.0000
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 33 33.000000 1584.4500 48.0136
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 5 5.000000 119.6400 23.9280
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 26 26.000000 1327.3000 51.0500
Subtotal (Total Children Is Unduplicated) 489 558.750000 31897.8900 57.0879
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Total 3197.750000 129540.8900 40.5100
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Number of Children (Unduplicated) With at Least One Service 1175
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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 0 0.000000 0.0000 0.0000
D 81 106.250000 3968.7500 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
3402 3091.500000 125572.1400 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 3483 3197.750000 129540.8900 0.0000