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
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 783 800.000000 29600.0000 37.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 1474 6555.000000 242535.0000 37.0000
Subtotal (Total Children Is Unduplicated) 1505 7355.000000 272135.0000 37.0000
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Screening, Eval, and Assessment,Class #02
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 30 30.000000 759.3000 25.3100
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 30 30.000000 556.5000 18.5500
EVAL-96111-DEVELOPMENTAL EVALUATION 74 84.250000 4212.5000 50.0000
EXIT-EXIT-EXIT ASSESSMENT 115 135.750000 6787.5000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 26 21.000000 1575.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 27 22.500000 1687.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 36 33.500000 3106.7100 92.7376
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 47 54.500000 3024.7500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 109 86.500000 6487.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 158 135.000000 10125.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 313 383.500000 21284.2500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 191 190.500000 16100.5600 84.5174
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 121 122.000000 11371.2600 93.2070
MED-99204-OUTPATIENT VISIT, NEW, 45 MINS 1 1.000000 507.0000 507.0000
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 21 21.000000 1114.0300 53.0490
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 9 9.000000 459.4500 51.0500
Subtotal (Total Children Is Unduplicated) 574 1360.000000 89158.8100 65.5579
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Total 8715.000000 361293.8100 41.4565
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Number of Children (Unduplicated) With at Least One Service 1524
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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 265 404.250000 15105.3000 0.0000
P 2885 4598.000000 183314.1500 183403.3550
D 7 5.250000 194.2500 0.0000
S 1 1.500000 55.5000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
3787 3704.500000 162569.1100 0.0000
Other 1 1.500000 55.5000 0.0000
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Total 6946 8715.000000 361293.8100 183403.3550