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
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 53.000000 1961.0000 37.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 37 221.500000 8195.5000 37.0000
Subtotal (Total Children Is Unduplicated) 85 274.500000 10156.5000 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 1.500000 83.2500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 7 6.500000 487.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 5 3.500000 262.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 32 22.500000 1248.7500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 10 7.000000 525.0000 75.0000
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 9 9.000000 530.1900 58.9100
Subtotal (Total Children Is Unduplicated) 43 50.500000 3174.6900 62.8651
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Total 325.000000 13331.1900 41.0190
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Number of Children (Unduplicated) With at Least One Service 91
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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 0 0.000000 0.0000 0.0000
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
286 320.000000 13146.1900 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 287 325.000000 13331.1900 0.0000