CMS/EIP Fiscal Report Center: 04
Services beginning 10/01/2018 ending 12/31/2018 Date of Report:02/06/2019 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 972 998.500000 36944.5000 37.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 1553 7359.000000 272283.0000 37.0000
Subtotal (Total Children Is Unduplicated) 1592 8357.500000 309227.5000 37.0000
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Screening, Eval, and Assessment,Class #02
EVAL-96111-DEVELOPMENTAL EVALUATION 74 81.250000 4062.5000 50.0000
EXIT-EXIT-EXIT ASSESSMENT 111 121.750000 6087.5000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 16 14.000000 1050.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 16 13.000000 975.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 21 20.500000 1743.9400 85.0702
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 30 36.500000 2025.7500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 113 93.500000 7012.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 157 130.500000 9787.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 318 378.000000 20979.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 161 168.500000 14065.3600 83.4739
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 76 76.000000 7348.6900 96.6933
MED-99204-OUTPATIENT VISIT, NEW, 45 MINS 11 11.000000 1920.2500 174.5682
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 16 16.000000 439.8500 27.4906
MED-99214-OUTPATIENT VISIT, EST, 25 MINS 1 1.000000 36.4900 36.4900
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 11 11.000000 561.5500 51.0500
Subtotal (Total Children Is Unduplicated) 551 1172.500000 78095.8800 66.6063
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Total 9530.000000 387323.3800 40.6425
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Number of Children (Unduplicated) With at Least One Service 1605
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Center 04
Flag Claims Units Chgs Paid
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R 8 8.500000 314.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 1102 1621.250000 62689.0000 0.0000
P 2462 3914.750000 156827.7900 156939.0300
D 28 37.500000 1387.5000 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
4265 3948.000000 166104.5900 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 7865 9530.000000 387323.3800 156939.0300