CMS/EIP Fiscal Report Center: 53
Services beginning 04/01/2012 ending 06/30/2012 Date of Report:08/16/2012 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 63 318.750000 11756.7500 36.8839
Subtotal (Total Children Is Unduplicated) 63 318.750000 11756.7500 36.8839
-----------------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 2.000000 150.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 2 4.000000 300.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 2 4.000000 222.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 2 4.000000 300.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 3 6.000000 450.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 34 63.500000 3524.2500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 36 66.000000 4950.0000 75.0000
Subtotal (Total Children Is Unduplicated) 43 149.500000 9896.2500 66.1957
-----------------------------------------------------------------------------------------------------------------------
EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 1 1.000000 50.0000 50.0000
Subtotal (Total Children Is Unduplicated) 1 1.000000 50.0000 50.0000
-----------------------------------------------------------------------------------------------------------------------
Total 469.250000 21703.0000 46.2504
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 63
-----------------------------------------------------------------------------------------------------------------------
Center 53
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 1 1.500000 83.2500 0.0000
U 0 0.000000 0.0000 0.0000
B 80 89.000000 3313.0000 0.0000
P 260 326.750000 14470.7500 14470.7500
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
29 52.000000 3836.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 370 469.250000 21703.0000 14470.7500