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
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 74 265.750000 9832.7500 37.0000
Subtotal (Total Children Is Unduplicated) 74 265.750000 9832.7500 37.0000
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 1 0.500000 37.5000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 0.500000 37.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 3 2.500000 138.7500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 13 6.500000 487.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 1 0.500000 37.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 23 12.000000 900.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 59 49.000000 2719.5000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 3 4.000000 300.0000 75.0000
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 26 26.000000 1316.3800 50.6300
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 1 1.000000 32.5600 32.5600
Subtotal (Total Children Is Unduplicated) 66 102.500000 6007.1900 58.6067
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 1 13.000000 650.0000 50.0000
Subtotal (Total Children Is Unduplicated) 1 13.000000 650.0000 50.0000
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Total 381.250000 16489.9400 43.2523
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Number of Children (Unduplicated) With at Least One Service 88
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Center 04
Flag Claims Units Chgs Paid
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R 2 1.750000 64.7500 0.0000
U 0 0.000000 0.0000 0.0000
B 97 150.250000 5850.0000 0.0000
P 111 162.250000 6822.2300 6814.4400
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 3 13.000000 650.0000 450.0000
T 0 0.000000 0.0000 0.0000
68 54.000000 3102.9600 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 281 381.250000 16489.9400 7264.4400