CMS/EIP Fiscal Report Center: 10
Services beginning 10/01/2012 ending 12/31/2012 Date of Report:02/16/2013 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 1521 4417.500000 163447.5000 37.0000
Subtotal (Total Children Is Unduplicated) 1521 4417.500000 163447.5000 37.0000
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 12 19.500000 1462.5000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 5 7.500000 562.5000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 5 9.000000 675.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 3 4.000000 300.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 19 35.000000 1942.5000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 115 204.000000 15300.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 36 55.500000 4162.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 54 95.000000 7125.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 141 265.500000 14735.2500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 106 130.000000 9750.0000 75.0000
Subtotal (Total Children Is Unduplicated) 232 825.000000 56015.2500 67.8973
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Total 5242.500000 219462.7500 41.8622
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Number of Children (Unduplicated) With at Least One Service 1521
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Center 10
Flag Claims Units Chgs Paid
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R 220 120.750000 4467.7500 0.0000
U 0 0.000000 0.0000 0.0000
B 7459 5101.500000 213632.0000 0.0000
P 9 16.500000 1120.5000 1120.5000
D 0 0.000000 0.0000 0.0000
S 1 0.250000 9.2500 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
3 3.500000 233.2500 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 7692 5242.500000 219462.7500 1120.5000