CMS/EIP Fiscal Report Center: 02
Services beginning 10/01/2012 ending 12/31/2012 Date of Report:02/16/2013 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 45 128.250000 4652.7500 36.2788
Subtotal (Total Children Is Unduplicated) 45 128.250000 4652.7500 36.2788
-----------------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 1 1.500000 112.5000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 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 13 24.500000 1837.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 10 18.500000 1387.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 11 21.000000 1165.5000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 6 12.000000 900.0000 75.0000
Subtotal (Total Children Is Unduplicated) 24 85.500000 5925.0000 69.2982
-----------------------------------------------------------------------------------------------------------------------
Total 213.750000 10577.7500 49.4865
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 45
-----------------------------------------------------------------------------------------------------------------------
Center 02
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 104 101.750000 3672.2500 0.0000
P 0 0.000000 0.0000 0.0000
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
70 112.000000 6905.5000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 174 213.750000 10577.7500 0.0000