CMS/EIP Fiscal Report Center: 04
Services beginning 01/01/2016 ending 03/31/2016 Date of Report:05/12/2016 Page: 1
List order: No List
Agency Filter:EIP DEI DEIP
Payclass Filters:MED
Eligibility Filter:Part C (excluding not eligible)
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 972 3979.750000 147250.7500 37.0000
Subtotal (Total Children Is Unduplicated) 972 3979.750000 147250.7500 37.0000
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 13 8.500000 637.5000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 20 16.000000 1200.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 3 1.500000 112.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 20 22.500000 1687.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 38 37.500000 2081.2500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 43 24.500000 1837.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 29 19.500000 1462.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 79 50.000000 3750.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 230 217.000000 12043.5000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 96 66.000000 4950.0000 75.0000
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 14 14.000000 567.0000 40.5000
MED-99204-OUTPATIENT VISIT, NEW, 45 MINS 1 1.000000 57.2700 57.2700
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 2 2.000000 44.2800 22.1400
Subtotal (Total Children Is Unduplicated) 283 480.000000 30430.8000 63.3975
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Total 4459.750000 177681.5500 39.8411
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Number of Children (Unduplicated) With at Least One Service 993
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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 135 182.750000 7749.7500 0.0000
P 2684 3995.500000 155224.6400 155277.7600
D 1 0.750000 27.7500 0.0000
S 2 4.250000 157.2500 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
276 276.500000 14522.1600 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 3098 4459.750000 177681.5500 155277.7600