CMS/EIP Fiscal Report Center: 04
Services beginning 01/01/2017 ending 03/31/2017 Date of Report:05/05/2017 Page: 1
List order: No List
Payclass Filters:GR
Eligibility Filter:Not Part C
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
CASE-CASE-NON-TCM CASE MANAGEMENT 56 43.500000 1609.5000 37.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 46 235.500000 8713.5000 37.0000
Subtotal (Total Children Is Unduplicated) 74 279.000000 10323.0000 37.0000
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Screening, Eval, and Assessment,Class #02
EVAL-96111-DEVELOPMENTAL EVALUATION 1 0.500000 25.0000 50.0000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 13 11.500000 862.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 11 9.000000 675.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 8 4.500000 337.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 52 44.500000 2469.7500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 9 5.500000 412.5000 75.0000
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 9 9.000000 416.7000 46.3000
Subtotal (Total Children Is Unduplicated) 63 84.500000 5198.9500 61.5260
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EI Services,Class #03
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 1 13.000000 130.0000 10.0000
Subtotal (Total Children Is Unduplicated) 1 13.000000 130.0000 10.0000
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Total 376.500000 15651.9500 41.5722
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Number of Children (Unduplicated) With at Least One Service 84
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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 3 13.000000 130.0000 130.0000
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
317 363.500000 15521.9500 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 320 376.500000 15651.9500 130.0000