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
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 783 800.000000 29600.0000 37.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 458 1914.750000 70845.7500 37.0000
Subtotal (Total Children Is Unduplicated) 993 2714.750000 100445.7500 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 10 9.500000 712.5000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 8 6.500000 487.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 12 8.500000 637.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 25 17.500000 971.2500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 33 25.500000 1912.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 48 42.000000 3150.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 195 169.500000 9407.2500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 69 48.500000 3637.5000 75.0000
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 56 56.000000 2998.8000 53.5500
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 9 9.000000 239.4900 26.6100
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 9 9.000000 459.4500 51.0500
Subtotal (Total Children Is Unduplicated) 490 681.500000 36929.5400 54.1886
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Total 3396.250000 137375.2900 40.4491
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Number of Children (Unduplicated) With at Least One Service 1167
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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 1 0.500000 18.5000 18.5000
D 7 5.250000 194.2500 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
3463 3390.500000 137162.5400 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 3471 3396.250000 137375.2900 18.5000