CMS/EIP Fiscal Report Center: 04
Services beginning 10/01/2017 ending 12/31/2017 Date of Report:02/03/2018 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 83 513.000000 18981.0000 37.0000
Subtotal (Total Children Is Unduplicated) 83 513.000000 18981.0000 37.0000
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 3 2.000000 150.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 3 2.000000 111.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 28 21.000000 1575.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 34 26.000000 1950.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 68 64.000000 3552.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 25 15.000000 1125.0000 75.0000
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 10 10.000000 535.5000 53.5500
Subtotal (Total Children Is Unduplicated) 76 140.000000 8998.5000 64.2750
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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 666.000000 28629.5000 42.9872
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Number of Children (Unduplicated) With at Least One Service 85
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Center 04
Flag Claims Units Chgs Paid
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R 4 15.500000 573.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 42 72.750000 3106.2500 0.0000
P 276 515.250000 21222.9000 21264.7800
D 0 0.000000 0.0000 0.0000
S 1 2.000000 74.0000 0.0000
H 3 13.000000 650.0000 0.0000
T 0 0.000000 0.0000 0.0000
59 47.500000 3002.8500 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 385 666.000000 28629.5000 21264.7800