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
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 972 998.500000 36944.5000 37.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 487 2184.500000 80826.5000 37.0000
Subtotal (Total Children Is Unduplicated) 1134 3183.000000 117771.0000 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-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 1.000000 75.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 6 4.500000 337.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 12 6.500000 360.7500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 11 8.000000 600.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 26 24.500000 1837.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 121 96.000000 5328.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 41 31.500000 2362.5000 75.0000
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 44 44.000000 2592.0400 58.9100
MED-99204-OUTPATIENT VISIT, NEW, 45 MINS 2 2.000000 166.5800 83.2900
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 5 5.000000 117.1000 23.4200
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 11 11.000000 561.5500 51.0500
Subtotal (Total Children Is Unduplicated) 383 437.000000 24488.5200 56.0378
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Total 3620.000000 142259.5200 39.2982
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Number of Children (Unduplicated) With at Least One Service 1249
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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 0 0.000000 0.0000 0.0000
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
3867 3582.500000 140872.0200 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 3895 3620.000000 142259.5200 0.0000