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
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 1219 5483.000000 202871.0000 37.0000
Subtotal (Total Children Is Unduplicated) 1219 5483.000000 202871.0000 37.0000
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 19 13.500000 1012.5000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 17 13.000000 975.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 15 9.000000 675.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 28 33.500000 2512.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 27 28.000000 1554.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 140 108.000000 8100.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 122 95.000000 7125.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 74 48.000000 3600.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 243 245.000000 13597.5000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 162 153.500000 11512.5000 75.0000
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 36 36.000000 1875.6000 52.1000
MED-99204-OUTPATIENT VISIT, NEW, 45 MINS 1 1.000000 75.7200 75.7200
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 7 7.000000 181.8000 25.9714
Subtotal (Total Children Is Unduplicated) 398 790.500000 52797.1200 66.7895
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Total 6273.500000 255668.1200 40.7537
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Number of Children (Unduplicated) With at Least One Service 1224
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Center 04
Flag Claims Units Chgs Paid
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R 1 1.000000 55.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 695 897.750000 39948.0000 0.0000
P 3135 4722.750000 185843.3900 186007.9000
D 0 0.000000 0.0000 0.0000
S 2 2.000000 74.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
513 650.000000 29747.2300 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 4346 6273.500000 255668.1200 186007.9000