CMS/EIP Fiscal Report Center: 04
Services beginning 10/01/2018 ending 12/31/2018 Date of Report:02/06/2019 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 53.000000 1961.0000 37.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 103 648.500000 23994.5000 37.0000
Subtotal (Total Children Is Unduplicated) 104 701.500000 25955.5000 37.0000
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 3 3.000000 225.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 2 1.000000 75.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 2 2.500000 187.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 5 5.500000 305.2500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 36 29.500000 2212.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 38 32.000000 2400.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 90 94.000000 5191.5000 55.2287
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 49 44.000000 4042.1800 91.8677
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 14 14.000000 1152.9100 82.3507
Subtotal (Total Children Is Unduplicated) 97 225.500000 15791.8400 70.0303
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Total 927.000000 41747.3400 45.0349
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Number of Children (Unduplicated) With at Least One Service 104
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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 61 103.000000 4404.2500 0.0000
P 214 390.750000 16645.6700 16645.6700
D 1 5.000000 185.0000 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
409 428.250000 20512.4200 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 685 927.000000 41747.3400 16645.6700