CMS/EIP Fiscal Report Center: 04
Services beginning 07/01/2019 ending 09/30/2019 Date of Report:11/04/2019 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 82 55.000000 2035.0000 37.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 117 731.500000 27065.5000 37.0000
Subtotal (Total Children Is Unduplicated) 117 786.500000 29100.5000 37.0000
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 2 1.500000 112.5000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 1.000000 75.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 2 1.500000 112.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 3 3.500000 194.2500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 34 24.500000 1837.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 43 34.000000 2550.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 95 102.000000 5661.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 66 64.500000 5002.7400 77.5619
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 8 8.000000 961.4600 120.1825
Subtotal (Total Children Is Unduplicated) 104 240.500000 16506.9500 68.6360
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Total 1027.000000 45607.4500 44.4084
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Number of Children (Unduplicated) With at Least One Service 119
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Center 04
Flag Claims Units Chgs Paid
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R 36 72.000000 2664.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 61 105.750000 4590.7500 0.0000
P 243 385.000000 16645.4900 16851.4900
D 0 0.000000 0.0000 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
441 464.250000 21707.2100 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 781 1027.000000 45607.4500 16851.4900