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
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 76 70.750000 2617.7500 37.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 49 224.000000 8288.0000 37.0000
Subtotal (Total Children Is Unduplicated) 94 294.750000 10905.7500 37.0000
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 1 1.000000 75.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 1 0.500000 37.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 2 1.000000 55.5000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 14 11.500000 862.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 11 10.500000 787.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 55 50.000000 2775.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 21 14.500000 1087.5000 75.0000
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 15 15.000000 803.2500 53.5500
Subtotal (Total Children Is Unduplicated) 74 104.000000 6483.7500 62.3438
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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 411.750000 17519.5000 42.5489
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Number of Children (Unduplicated) With at Least One Service 109
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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 4 10.000000 370.0000 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
353 388.750000 17019.5000 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 360 411.750000 17519.5000 130.0000