CMS/EIP Fiscal Report Center: 04
Services beginning 10/01/2018 ending 12/31/2018 Date of Report:02/06/2019 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 68 427.000000 15799.0000 37.0000
Subtotal (Total Children Is Unduplicated) 68 427.000000 15799.0000 37.0000
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 2 2.000000 150.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 0.500000 37.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 3 3.000000 166.5000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 21 17.500000 1312.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 26 21.500000 1612.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 60 51.500000 2858.2500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 20 13.000000 975.0000 75.0000
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 2 2.000000 117.8200 58.9100
Subtotal (Total Children Is Unduplicated) 64 111.000000 7230.0700 65.1358
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Total 538.000000 23029.0700 42.8050
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Number of Children (Unduplicated) With at Least One Service 68
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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 61 103.000000 4404.2500 0.0000
P 207 383.750000 15356.5000 15356.5000
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
61 51.250000 3268.3200 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 329 538.000000 23029.0700 15356.5000