CMS/EIP Fiscal Report Center: 04
Services beginning 07/01/2019 ending 09/30/2019 Date of Report:11/04/2019 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 1296 6013.000000 222426.5000 36.9909
Subtotal (Total Children Is Unduplicated) 1296 6013.000000 222426.5000 36.9909
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 11 8.500000 637.5000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 9 7.000000 525.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 0.500000 37.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 24 22.500000 1687.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 24 23.500000 1304.2500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 108 80.000000 6000.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 117 85.500000 6412.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 241 226.500000 12570.7500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 119 105.500000 7912.5000 75.0000
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 6 6.000000 353.4600 58.9100
MED-99204-OUTPATIENT VISIT, NEW, 45 MINS 1 1.000000 83.2900 83.2900
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 2 2.000000 46.8400 23.4200
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 1 1.000000 51.0500 51.0500
Subtotal (Total Children Is Unduplicated) 296 569.500000 37622.1400 66.0617
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Total 6582.500000 260048.6400 39.5061
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Number of Children (Unduplicated) With at Least One Service 1311
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Center 04
Flag Claims Units Chgs Paid
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R 490 783.750000 28962.7500 0.0000
U 0 0.000000 0.0000 0.0000
B 733 980.500000 38992.5000 0.0000
P 3238 4671.750000 182480.0000 180726.1800
D 1 1.500000 55.5000 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
172 145.000000 9557.8900 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 4634 6582.500000 260048.6400 180726.1800