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
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 1105 3649.750000 135040.7500 37.0000
Subtotal (Total Children Is Unduplicated) 1105 3649.750000 135040.7500 37.0000
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 6 5.000000 375.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 4 3.500000 262.5000 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 1 2.000000 150.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 14 14.000000 777.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 49 25.000000 1875.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 8 5.000000 375.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 64 41.500000 3112.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 188 160.500000 8907.7500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 11 16.500000 1237.5000 75.0000
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 101 101.000000 5113.6300 50.6300
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 18 18.000000 586.0800 32.5600
Subtotal (Total Children Is Unduplicated) 239 392.500000 22809.4600 58.1133
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Total 4042.250000 157850.2100 39.0501
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Number of Children (Unduplicated) With at Least One Service 1106
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Center 04
Flag Claims Units Chgs Paid
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R 23 31.750000 1174.7500 0.0000
U 0 0.000000 0.0000 0.0000
B 889 1065.250000 41132.5000 0.0000
P 2217 2501.250000 95066.8800 94802.9900
D 1 0.500000 18.5000 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
386 438.750000 20281.8300 0.0000
Other 4 4.750000 175.7500 0.0000
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Total 3520 4042.250000 157850.2100 94802.9900