CMS/EIP Fiscal Report Center: 04
Services beginning 10/01/2011 ending 12/31/2011 Date of Report:02/16/2012 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 1211 4768.000000 176387.0000 36.9939
Subtotal (Total Children Is Unduplicated) 1211 4768.000000 176387.0000 36.9939
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 3 1.500000 112.5000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 3 1.500000 112.5000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 6 4.500000 337.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 6 8.000000 600.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 30 31.000000 1720.5000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 79 42.000000 3150.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 5 2.500000 187.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 66 42.500000 3187.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 258 225.500000 12515.2500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 6 7.500000 562.5000 75.0000
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 55 55.000000 9886.0000 179.7455
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 13 13.000000 1365.0000 105.0000
Subtotal (Total Children Is Unduplicated) 302 434.500000 33736.7500 77.6450
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Total 5202.500000 210123.7500 40.3890
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Number of Children (Unduplicated) With at Least One Service 1216
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Center 04
Flag Claims Units Chgs Paid
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R 1 0.750000 27.7500 0.0000
U 0 0.000000 0.0000 0.0000
B 2403 2702.750000 102366.7500 0.0000
P 2398 2499.000000 107729.2500 99993.9000
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 4802 5202.500000 210123.7500 99993.9000