CMS/EIP Fiscal Report Center: 04
Services beginning 10/01/2016 ending 12/31/2016 Date of Report:02/04/2017 Page: 1
List order: No List
Eligibility Filter:DEI Only
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
CASE-CASE-NON-TCM CASE MANAGEMENT 29 20.500000 758.5000 37.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 32 48.750000 1803.7500 37.0000
Subtotal (Total Children Is Unduplicated) 36 69.250000 2562.2500 37.0000
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Screening, Eval, and Assessment,Class #02
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 1 0.500000 37.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 1 0.500000 27.7500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 1 0.500000 37.5000 75.0000
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 1 1.000000 40.5000 40.5000
Subtotal (Total Children Is Unduplicated) 1 2.500000 143.2500 57.3000
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Total 71.750000 2705.5000 37.7073
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Number of Children (Unduplicated) With at Least One Service 36
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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 10 10.750000 429.5000 492.7700
D 0 0.000000 0.0000 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
79 61.000000 2276.0000 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 89 71.750000 2705.5000 492.7700