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
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 1148 4605.750000 170412.7500 37.0000
Subtotal (Total Children Is Unduplicated) 1148 4605.750000 170412.7500 37.0000
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 16 11.000000 825.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 28 24.500000 1837.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 10 9.500000 712.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 37 36.000000 1998.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 66 52.500000 3937.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 119 110.500000 8287.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 204 194.500000 10794.7500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 68 59.000000 4425.0000 75.0000
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 36 36.000000 1927.8000 53.5500
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 8 8.000000 212.8800 26.6100
MED-99214-OUTPATIENT VISIT, EST, 25 MINS 1 1.000000 41.4600 41.4600
Subtotal (Total Children Is Unduplicated) 267 542.500000 34999.8900 64.5159
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Total 5148.250000 205412.6400 39.8995
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Number of Children (Unduplicated) With at Least One Service 1156
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Center 04
Flag Claims Units Chgs Paid
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R 39 45.500000 1683.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 492 813.000000 31478.0000 0.0000
P 2577 4078.250000 159173.8400 159286.8400
D 0 0.000000 0.0000 0.0000
S 1 3.000000 111.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
228 208.500000 12966.3000 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 3337 5148.250000 205412.6400 159286.8400