CMS/EIP Fiscal Report Center: 04
Services beginning 01/01/2013 ending 03/31/2013 Date of Report:05/17/2013 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 1126 3790.750000 140257.7500 37.0000
Subtotal (Total Children Is Unduplicated) 1126 3790.750000 140257.7500 37.0000
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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 2 1.500000 112.5000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 10 5.500000 412.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 2 3.500000 262.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 21 19.500000 1082.2500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 27 15.500000 1162.5000 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 35.000000 2625.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 141 129.500000 7187.2500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 8 13.000000 975.0000 75.0000
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 46 46.000000 2328.9800 50.6300
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 7 7.000000 227.9200 32.5600
Subtotal (Total Children Is Unduplicated) 202 282.500000 16863.9000 59.6952
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Total 4073.250000 157121.6500 38.5740
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Number of Children (Unduplicated) With at Least One Service 1172
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Center 04
Flag Claims Units Chgs Paid
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R 124 71.750000 2654.7500 0.0000
U 0 0.000000 0.0000 0.0000
B 2004 2094.250000 80461.0000 0.0000
P 1537 1907.250000 74005.9000 73963.7600
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 3665 4073.250000 157121.6500 73963.7600