CMS/EIP Fiscal Report Center: 04
Services beginning 10/01/2015 ending 12/31/2015 Date of Report:02/13/2016 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 37 165.250000 6114.2500 37.0000
Subtotal (Total Children Is Unduplicated) 37 165.250000 6114.2500 37.0000
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 1.000000 75.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 0.500000 37.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 2 2.500000 138.7500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 18 10.500000 787.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 15 8.000000 600.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 40 35.000000 1942.5000 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 3 3.000000 121.5000 40.5000
Subtotal (Total Children Is Unduplicated) 44 67.500000 4227.7500 62.6333
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Total 232.750000 10342.0000 44.4339
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Number of Children (Unduplicated) With at Least One Service 54
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Center 04
Flag Claims Units Chgs Paid
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R 1 0.250000 9.2500 0.0000
U 0 0.000000 0.0000 0.0000
B 24 47.000000 1776.5000 0.0000
P 96 145.000000 6201.7500 6201.7500
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
49 40.500000 2354.5000 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 170 232.750000 10342.0000 6201.7500