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
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 1004 3484.750000 128935.7500 37.0000
Subtotal (Total Children Is Unduplicated) 1004 3484.750000 128935.7500 37.0000
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 7 3.500000 262.5000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 4 2.500000 187.5000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 16 10.000000 750.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 4 5.500000 412.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 35 33.500000 1859.2500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 26 15.000000 1125.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 8 5.500000 412.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 86 54.000000 4050.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 204 181.000000 10045.5000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 10 16.000000 1200.0000 75.0000
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 113 113.000000 5721.1900 50.6300
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 19 19.000000 618.6400 32.5600
Subtotal (Total Children Is Unduplicated) 272 458.500000 26644.5800 58.1125
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Total 3943.250000 155580.3300 39.4548
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Number of Children (Unduplicated) With at Least One Service 1058
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Center 04
Flag Claims Units Chgs Paid
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R 112 62.500000 2312.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 1778 1865.500000 71706.5000 0.0000
P 1380 1702.000000 65592.6700 65558.3200
D 1 1.250000 46.2500 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
328 309.750000 15839.1600 0.0000
Other 3 2.250000 83.2500 0.0000
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Total 3602 3943.250000 155580.3300 65558.3200