CMS/EIP Fiscal Report Center: 04
Services beginning 10/01/2016 ending 12/31/2016 Date of Report:02/04/2017 Page: 1
List order: No List
Payclass Filters:MED
Bill Flag Filter:RBPU
Eligibility Filter:All
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 1179 4406.750000 163049.7500 37.0000
Subtotal (Total Children Is Unduplicated) 1179 4406.750000 163049.7500 37.0000
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 14 10.000000 750.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 14 11.500000 862.5000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 7 3.500000 262.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 21 18.000000 1350.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 22 21.000000 1165.5000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 86 67.000000 5025.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 86 70.500000 5287.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 54 30.500000 2287.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 186 173.000000 9601.5000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 58 47.000000 3525.0000 75.0000
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 14 14.000000 567.0000 40.5000
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 1 1.000000 22.1400 22.1400
Subtotal (Total Children Is Unduplicated) 235 467.000000 30706.1400 65.7519
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Total 4873.750000 193755.8900 39.7550
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Number of Children (Unduplicated) With at Least One Service 1183
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Center 04
Flag Claims Units Chgs Paid
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R 3 7.500000 277.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 65 102.500000 3792.5000 0.0000
P 3369 4763.750000 189685.8900 190178.4500
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
0 0.000000 0.0000 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 3437 4873.750000 193755.8900 190178.4500