CMS/EIP Fiscal Report Center: 55
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 64 337.750000 12478.2500 36.9452
Subtotal (Total Children Is Unduplicated) 64 337.750000 12478.2500 36.9452
-----------------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 25 44.500000 3337.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 28 49.500000 3712.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 8 12.000000 900.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 8 12.500000 693.7500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 21 31.500000 2362.5000 75.0000
Subtotal (Total Children Is Unduplicated) 49 150.000000 11006.2500 73.3750
-----------------------------------------------------------------------------------------------------------------------
Total 487.750000 23484.5000 48.1486
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 64
-----------------------------------------------------------------------------------------------------------------------
Center 55
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 20 25.250000 991.2500 0.0000
P 307 342.000000 13775.5000 13775.5000
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
70 120.500000 8717.7500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 397 487.750000 23484.5000 13775.5000