CMS/EIP Fiscal Report Center: 04
Services beginning 07/01/2019 ending 09/30/2019 Date of Report:11/04/2019 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 1083 1191.250000 44076.2500 37.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 1689 8178.250000 302540.7500 36.9933
Subtotal (Total Children Is Unduplicated) 1727 9369.500000 346617.0000 36.9942
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Screening, Eval, and Assessment,Class #02
EVAL-96111-DEVELOPMENTAL EVALUATION 86 87.500000 4375.0000 50.0000
EXIT-EXIT-EXIT ASSESSMENT 112 111.250000 5562.5000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 16 13.000000 975.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 13 10.500000 787.5000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 0.500000 37.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 33 34.000000 2550.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 31 35.000000 1942.5000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 143 106.000000 7950.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 160 119.500000 8962.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 330 378.500000 21006.7500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 200 196.500000 14957.8100 76.1212
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 34 34.000000 3963.6600 116.5782
MED-99204-OUTPATIENT VISIT, NEW, 45 MINS 5 5.000000 1263.8700 252.7740
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 6 6.000000 140.5200 23.4200
MED-99214-OUTPATIENT VISIT, EST, 25 MINS 1 1.000000 36.4900 36.4900
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 12 13.000000 663.6500 51.0500
Subtotal (Total Children Is Unduplicated) 591 1151.250000 75175.2500 65.2988
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Total 10520.750000 421792.2500 40.0915
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Number of Children (Unduplicated) With at Least One Service 1740
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Center 04
Flag Claims Units Chgs Paid
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R 490 783.750000 28962.7500 0.0000
U 0 0.000000 0.0000 0.0000
B 733 980.500000 38992.5000 0.0000
P 3243 4675.250000 182943.8100 181208.4900
D 18 21.500000 899.2500 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
4592 4059.750000 169993.9400 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 9076 10520.750000 421792.2500 181208.4900