CMS/EIP Fiscal Report Center: 04
Services beginning 01/01/2017 ending 03/31/2017 Date of Report:05/05/2017 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 63 334.000000 12358.0000 37.0000
Subtotal (Total Children Is Unduplicated) 63 334.000000 12358.0000 37.0000
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Screening, Eval, and Assessment,Class #02
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 19 13.000000 975.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 15 11.000000 825.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 19 11.000000 825.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 36 31.000000 1720.5000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 23 16.500000 1237.5000 75.0000
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 1 1.000000 53.5500 53.5500
Subtotal (Total Children Is Unduplicated) 54 83.500000 5636.5500 67.5036
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 1 13.000000 650.0000 50.0000
Subtotal (Total Children Is Unduplicated) 1 13.000000 650.0000 50.0000
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Total 430.500000 18644.5500 43.3091
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Number of Children (Unduplicated) With at Least One Service 63
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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 54 68.000000 3185.7500 0.0000
P 178 311.750000 12572.7500 12572.7500
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 3 13.000000 650.0000 0.0000
T 0 0.000000 0.0000 0.0000
44 37.750000 2236.0500 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 279 430.500000 18644.5500 12572.7500