CMS/EIP Fiscal Report Center: 04
Services beginning 10/01/2013 ending 12/31/2013 Date of Report:02/18/2014 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 1108 4095.750000 151443.0000 36.9756
Subtotal (Total Children Is Unduplicated) 1108 4095.750000 151443.0000 36.9756
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 2 1.000000 75.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 5 2.500000 187.5000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 3 2.500000 187.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 20 20.000000 1500.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 20 19.000000 1054.5000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 39 25.000000 1875.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 12 9.500000 712.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 61 38.000000 2850.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 158 143.000000 7936.5000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 111 104.500000 7837.5000 75.0000
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 4 4.000000 202.5200 50.6300
MED-99212-OUTPATIENT VISIT, EST, 10 MINS 3 3.000000 79.3500 26.4500
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 11 11.000000 352.9300 32.0845
Subtotal (Total Children Is Unduplicated) 238 383.000000 24850.8000 64.8846
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Total 4478.750000 176293.8000 39.3623
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Number of Children (Unduplicated) With at Least One Service 1112
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Center 04
Flag Claims Units Chgs Paid
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R 22 20.500000 1328.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 1584 1988.000000 75776.7500 0.0000
P 1753 2177.250000 83265.4900 83301.2300
D 0 0.000000 0.0000 0.0000
S 2 1.250000 46.2500 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
288 285.500000 15645.5600 0.0000
Other 5 6.250000 231.2500 0.0000
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Total 3654 4478.750000 176293.8000 83301.2300