CMS/EIP Fiscal Report Center: 04
Services beginning 10/01/2011 ending 12/31/2011 Date of Report:02/15/2012 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 114 557.000000 20609.0000 37.0000
Subtotal (Total Children Is Unduplicated) 114 557.000000 20609.0000 37.0000
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Screening, Eval, and Assessment,Class #02
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 42 21.500000 1612.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 3 1.500000 112.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 14 8.500000 637.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 92 80.500000 4467.7500 55.5000
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 36 36.000000 6515.5000 180.9861
Subtotal (Total Children Is Unduplicated) 93 148.000000 13345.7500 90.1740
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Total 705.000000 33954.7500 48.1628
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Number of Children (Unduplicated) With at Least One Service 117
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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 218 307.750000 12260.7500 0.0000
P 255 356.500000 17814.7500 15410.0000
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
30 40.750000 3879.2500 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 503 705.000000 33954.7500 15410.0000