CMS/EIP Fiscal Report Center: 04
Services beginning 01/01/2018 ending 03/31/2018 Date of Report:05/05/2018 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 66 60.750000 2247.7500 37.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 46 271.250000 10036.2500 37.0000
Subtotal (Total Children Is Unduplicated) 85 332.000000 12284.0000 37.0000
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Screening, Eval, and Assessment,Class #02
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 5 5.000000 126.5500 25.3100
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 5 5.000000 92.7500 18.5500
EVAL-96111-DEVELOPMENTAL EVALUATION 2 2.250000 112.5000 50.0000
EXIT-EXIT-EXIT ASSESSMENT 1 1.500000 75.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 1 1.000000 75.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 2 1.000000 75.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 3 4.500000 249.7500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 13 9.500000 712.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 16 13.500000 1012.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 69 56.500000 3135.7500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 16 11.000000 825.0000 75.0000
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 10 10.000000 535.5000 53.5500
Subtotal (Total Children Is Unduplicated) 88 120.750000 7027.8000 58.2012
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EI Services,Class #03
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 2 15.000000 150.0000 10.0000
Subtotal (Total Children Is Unduplicated) 2 15.000000 150.0000 10.0000
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Total 467.750000 19461.8000 41.6073
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Number of Children (Unduplicated) With at Least One Service 102
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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 4 15.000000 150.0000 150.0000
D 1 0.500000 18.5000 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
390 452.250000 19293.3000 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 395 467.750000 19461.8000 150.0000