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
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 58 324.250000 11997.2500 37.0000
Subtotal (Total Children Is Unduplicated) 58 324.250000 11997.2500 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 0.500000 27.7500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 31 24.500000 1837.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 20 16.500000 1237.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 8 5.000000 375.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 50 47.000000 2608.5000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 12 10.500000 787.5000 75.0000
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 3 3.000000 121.5000 40.5000
Subtotal (Total Children Is Unduplicated) 55 107.500000 7032.7500 65.4209
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 1 3.000000 150.0000 50.0000
Subtotal (Total Children Is Unduplicated) 1 3.000000 150.0000 50.0000
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Total 434.750000 19180.0000 44.1173
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Number of Children (Unduplicated) With at Least One Service 60
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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 3 7.750000 286.7500 0.0000
P 237 404.500000 17490.2500 17593.3700
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 2 3.000000 150.0000 0.0000
T 0 0.000000 0.0000 0.0000
21 19.500000 1253.0000 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 263 434.750000 19180.0000 17593.3700