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
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 1059 4007.750000 148286.7500 37.0000
Subtotal (Total Children Is Unduplicated) 1059 4007.750000 148286.7500 37.0000
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 18 13.000000 975.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 18 15.000000 1125.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 8 4.000000 300.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 23 19.500000 1462.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 29 28.000000 1554.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 81 62.000000 4650.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 80 67.000000 5025.0000 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 184 170.500000 9462.7500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 56 47.000000 3525.0000 75.0000
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 29 29.000000 1174.5000 40.5000
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 8 8.000000 177.1200 22.1400
Subtotal (Total Children Is Unduplicated) 240 493.500000 31718.3700 64.2723
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Total 4501.250000 180005.1200 39.9900
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Number of Children (Unduplicated) With at Least One Service 1061
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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 61 93.500000 3459.5000 0.0000
P 2963 4216.750000 166891.3900 167217.5600
D 0 0.000000 0.0000 0.0000
S 2 4.250000 157.2500 0.0000
H 0 0.000000 0.0000 0.0000
T 1 1.500000 55.5000 0.0000
185 177.750000 9163.9800 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 3215 4501.250000 180005.1200 167217.5600