CMS/EIP Fiscal Report Center: 04
Services beginning 10/01/2012 ending 12/31/2012 Date of Report:02/16/2013 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 1240 3929.000000 145373.0000 37.0000
Subtotal (Total Children Is Unduplicated) 1240 3929.000000 145373.0000 37.0000
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 2 1.500000 112.5000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 2 2.000000 150.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 5 6.000000 333.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 48 24.500000 1837.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 7 5.000000 375.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 55 34.000000 2550.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 122 108.000000 5994.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 4 7.500000 562.5000 75.0000
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 16 16.000000 810.0800 50.6300
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 3 3.000000 97.6800 32.5600
Subtotal (Total Children Is Unduplicated) 159 207.500000 12822.2600 61.7940
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Total 4136.500000 158195.2600 38.2437
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Number of Children (Unduplicated) With at Least One Service 1244
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Center 04
Flag Claims Units Chgs Paid
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R 25 34.500000 1276.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 999 1219.500000 47168.5000 0.0000
P 2501 2882.500000 109750.2600 109477.1200
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 3525 4136.500000 158195.2600 109477.1200