CMS/EIP Fiscal Report Center: 04
Services beginning 01/01/2018 ending 03/31/2018 Date of Report:05/05/2018 Page: 1
List order: No List
Payclass Filters:MED
Bill Flag Filter:RBPU
Eligibility Filter:All
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 1256 5229.500000 193491.5000 37.0000
Subtotal (Total Children Is Unduplicated) 1256 5229.500000 193491.5000 37.0000
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 9 6.000000 450.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 15 12.000000 900.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 13 8.500000 637.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 18 19.500000 1082.2500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 75 58.000000 4350.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 102 84.000000 6300.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 202 191.000000 10600.5000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 55 40.500000 3037.5000 75.0000
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 10 10.000000 535.5000 53.5500
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 1 1.000000 26.6100 26.6100
Subtotal (Total Children Is Unduplicated) 241 430.500000 27919.8600 64.8545
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Total 5660.000000 221411.3600 39.1186
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Number of Children (Unduplicated) With at Least One Service 1275
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Center 04
Flag Claims Units Chgs Paid
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R 17 15.000000 555.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 303 459.750000 17158.8000 0.0000
P 3307 5185.250000 203697.5600 203833.0850
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
0 0.000000 0.0000 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 3627 5660.000000 221411.3600 203833.0850