CMS/EIP Fiscal Report Center: 04
Services beginning 01/01/2018 ending 03/31/2018 Date of Report:05/05/2018 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 66 60.750000 2247.7500 37.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 115 696.500000 25770.5000 37.0000
Subtotal (Total Children Is Unduplicated) 115 757.250000 28018.2500 37.0000
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Screening, Eval, and Assessment,Class #02
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 5 5.000000 126.5500 25.3100
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 5 5.000000 92.7500 18.5500
EVAL-96111-DEVELOPMENTAL EVALUATION 2 2.250000 112.5000 50.0000
EXIT-EXIT-EXIT ASSESSMENT 1 1.500000 75.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 1 1.000000 75.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 3 1.500000 112.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 2 3.000000 225.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 4 5.500000 305.2500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 43 31.000000 2325.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 45 35.500000 2662.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 94 115.500000 6410.2500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 45 40.500000 4065.6600 100.3867
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 24 24.000000 1840.9900 76.7079
Subtotal (Total Children Is Unduplicated) 105 271.250000 18428.9500 67.9408
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 2 15.000000 750.0000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 2 15.000000 150.0000 10.0000
Subtotal (Total Children Is Unduplicated) 2 30.000000 900.0000 30.0000
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Total 1058.500000 47347.2000 44.7305
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Number of Children (Unduplicated) With at Least One Service 116
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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 8 25.250000 934.2500 0.0000
P 277 499.000000 21800.5000 21846.8200
D 1 0.500000 18.5000 0.0000
S 0 0.000000 0.0000 0.0000
H 4 15.000000 750.0000 0.0000
T 0 0.000000 0.0000 0.0000
460 518.750000 23843.9500 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 750 1058.500000 47347.2000 21846.8200