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
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 94 438.500000 16224.5000 37.0000
Subtotal (Total Children Is Unduplicated) 94 438.500000 16224.5000 37.0000
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 1 1.000000 55.5000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 22 11.000000 825.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 4 2.500000 187.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 15 8.000000 600.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 71 53.500000 2969.2500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 2 3.000000 225.0000 75.0000
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 39 39.000000 1974.5700 50.6300
Subtotal (Total Children Is Unduplicated) 77 118.000000 6836.8200 57.9392
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Total 556.500000 23061.3200 41.4399
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Number of Children (Unduplicated) With at Least One Service 96
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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 66 113.000000 4509.7500 0.0000
P 189 319.750000 12407.8800 12398.6300
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
120 123.750000 6143.6900 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 375 556.500000 23061.3200 12398.6300