CMS/EIP Fiscal Report Center: 53
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 21 82.750000 3061.7500 37.0000
Subtotal (Total Children Is Unduplicated) 21 82.750000 3061.7500 37.0000
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 1 2.000000 150.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 1 2.000000 111.0000 55.5000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 1 1.500000 112.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 12 22.500000 1248.7500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 14 27.000000 2025.0000 75.0000
Subtotal (Total Children Is Unduplicated) 17 55.000000 3647.2500 66.3136
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Total 137.750000 6709.0000 48.7042
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Number of Children (Unduplicated) With at Least One Service 21
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Center 53
Flag Claims Units Chgs Paid
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R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 0 0.000000 0.0000 0.0000
P 94 114.750000 4984.0000 4984.0000
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
12 23.000000 1725.0000 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 106 137.750000 6709.0000 4984.0000