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
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 1077 4640.250000 171689.2500 37.0000
Subtotal (Total Children Is Unduplicated) 1077 4640.250000 171689.2500 37.0000
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 16 11.500000 862.5000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 19 16.000000 1200.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 18 14.500000 1087.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 30 37.000000 2053.5000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 75 60.500000 4537.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 110 93.000000 6975.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 223 212.500000 11793.7500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 76 58.500000 4387.5000 75.0000
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 43 44.000000 2356.2000 53.5500
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 8 8.000000 212.8800 26.6100
Subtotal (Total Children Is Unduplicated) 283 555.500000 35466.3300 63.8458
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Total 5195.750000 207155.5800 39.8702
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Number of Children (Unduplicated) With at Least One Service 1092
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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 265 404.250000 15105.3000 0.0000
P 2864 4578.000000 179173.9600 179263.1650
D 0 0.000000 0.0000 0.0000
S 1 1.500000 55.5000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
227 210.500000 12765.3200 0.0000
Other 1 1.500000 55.5000 0.0000
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Total 3358 5195.750000 207155.5800 179263.1650