CMS/EIP Fiscal Report Center: 04
Services beginning 10/01/2017 ending 12/31/2017 Date of Report:02/03/2018 Page: 1
List order: No List
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 76 70.750000 2617.7500 37.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 123 737.000000 27269.0000 37.0000
Subtotal (Total Children Is Unduplicated) 123 807.750000 29886.7500 37.0000
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 4 3.000000 225.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 1 1.000000 75.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 4 3.000000 166.5000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 42 32.500000 2437.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 45 36.500000 2737.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 100 114.000000 6327.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 61 54.000000 4438.1800 82.1885
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 33 33.000000 3345.1900 101.3694
Subtotal (Total Children Is Unduplicated) 107 277.000000 19751.8700 71.3064
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 1 13.000000 650.0000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 1 13.000000 130.0000 10.0000
Subtotal (Total Children Is Unduplicated) 1 26.000000 780.0000 30.0000
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Total 1110.750000 50418.6200 45.3915
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Number of Children (Unduplicated) With at Least One Service 123
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Center 04
Flag Claims Units Chgs Paid
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R 4 15.500000 573.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 42 72.750000 3106.2500 0.0000
P 285 534.250000 22223.5200 22265.4000
D 4 10.000000 370.0000 0.0000
S 1 2.000000 74.0000 0.0000
H 3 13.000000 650.0000 0.0000
T 0 0.000000 0.0000 0.0000
438 463.250000 23421.3500 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 777 1110.750000 50418.6200 22265.4000