CMS/EIP Fiscal Report Center: 04
Services beginning 10/01/2017 ending 12/31/2017 Date of Report:02/03/2018 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 807 720.250000 26649.2500 37.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 1485 5978.000000 221186.0000 37.0000
Subtotal (Total Children Is Unduplicated) 1539 6698.250000 247835.2500 37.0000
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Screening, Eval, and Assessment,Class #02
EVAL-96111-DEVELOPMENTAL EVALUATION 60 67.500000 3375.0000 50.0000
EXIT-EXIT-EXIT ASSESSMENT 120 131.500000 6575.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 19 13.000000 975.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 30 26.000000 1950.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 24 22.500000 1687.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 41 45.500000 2525.2500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 85 67.500000 5062.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 154 139.500000 10462.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 262 305.500000 16955.2500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 146 140.000000 11083.5000 79.1679
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 96 96.000000 8684.7700 90.4664
MED-99204-OUTPATIENT VISIT, NEW, 45 MINS 2 2.000000 151.4400 75.7200
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 13 13.000000 345.9300 26.6100
MED-99214-OUTPATIENT VISIT, EST, 25 MINS 1 1.000000 41.4600 41.4600
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 8 8.000000 408.4000 51.0500
Subtotal (Total Children Is Unduplicated) 504 1078.500000 70283.5000 65.1678
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Total 7776.750000 318118.7500 40.9064
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Number of Children (Unduplicated) With at Least One Service 1552
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Center 04
Flag Claims Units Chgs Paid
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R 39 45.500000 1683.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 492 813.000000 31478.0000 0.0000
P 2583 4083.250000 160148.5600 160261.5600
D 42 64.250000 2377.2500 0.0000
S 1 3.000000 111.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
2998 2767.750000 122320.4400 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 6155 7776.750000 318118.7500 160261.5600