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:MED
Eligibility Filter:Not Part C
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 73 425.250000 15734.2500 37.0000
Subtotal (Total Children Is Unduplicated) 73 425.250000 15734.2500 37.0000
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 0.500000 37.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 1 1.000000 55.5000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 30 21.500000 1612.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 29 22.000000 1650.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 66 59.000000 3274.5000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 13 7.500000 562.5000 75.0000
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 10 10.000000 535.5000 53.5500
Subtotal (Total Children Is Unduplicated) 69 121.500000 7728.0000 63.6049
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 2 15.000000 750.0000 50.0000
Subtotal (Total Children Is Unduplicated) 2 15.000000 750.0000 50.0000
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Total 561.750000 24212.2500 43.1015
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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 8 25.250000 934.2500 0.0000
P 262 473.000000 19556.3500 19602.6700
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 4 15.000000 750.0000 0.0000
T 0 0.000000 0.0000 0.0000
54 48.500000 2971.6500 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 328 561.750000 24212.2500 19602.6700